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If patient is a Full-time Student, Name of:
Is this visit due to an accident?
What is the patient's relationship to insured member?
Does your dental insurance require a referral or prior authorization?*
If yes, have you contacted your primary dentist for a referral?
Does your medical insurance require a referral or prior authorization?
If yes, have you contacted your primary physician for a referral?
I have read and answered the above questions to the best of my knowledge. I authorize and request my insurance company to pay directly to,, Northeast Surgical Specialists, otherwise payable to me. I authorize the provider/s to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance and that preauthorization of benefits does not guarantee payment. I authorize the use of this signature on all insurance submissions. I agree that I am responsible for all fees incurred if my account is turned over to a third party collector.
If Parent Signing is different from Insured Member:
A. Person's or Organization(s) authorized to provide the information:Northeast Surgical Specialists, PLLC and their Representatives
B. Person(s) or Organization(s) authorized to receive the information:*
C. Specific description of the information that may be used or disclosed (including date(s))*
D. Specific description of how the information will be used:
1) I understand that this authorization will expire on
2) I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying Northeast Surgical Specialists, PLLC in writing.
3) I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment or my eligibility for benefits (if applicable).
4) I may inspect or copy any information used or disclosed under this agreement.
5) I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be redisclosed and would no longer be protected by these regulations.
You have the right to know specifically what information you are authorizing for release (e.g., “results of a lab test performed on 1/4/03” or, if your entire medical record is included, “all health information.”).
You have the right to know the name(s) or other identification of the person(s) or organization(s) authorized to release the information (e.g., the names of your health care provider(s)).
You have the right to know who is going to use it and what it is going to be used for. (e.g., John Smith, PhD / Research).
For the following questions, select yes or no, whichever applies. Your answers are for our records only and will be kept confidential.
1) Why are you here today? (your chief complaint)*
2) Has there been any change in your health in the past year?*
3) My last physical exam was on*
4) The name of my physician*
5) Please list all hospitalizations, surgeries and / or serious illness*
6) Have you had an artificial joint replacement (knee, hip, shoulder, etc.)*
7) Are you taking or have you ever taken any Bisphosphonates, oral or IV, for osteoporosis or chemotherapy for multiple myeloma or metastatic cancer (These meds include: Reclast, Fosamax, Actonel, Boniva, Aredia, or Zometa)?*
8) Please list all medication(s) that you take currently:*
9) Any medications that “thin” your blood? Please select those that apply:*
10) Have you ever required an antibiotic prior to dental procedures?*
11) Do you have or have you had any of the following diseases or problems? Select those that apply:
a) Damaged heart valves, artificial heart valves or heart murmur*
b) Rheumatic Heart Disease*
c) Heart trouble, high blood pressure, arteriosclerosis or any other heart condition such as palpitations, irregular heart beat or congestive heart failure?*
1) Chest pain upon exertion? (angina)*
Is this new?*
Do you experience this at rest?*
2) Shortness of breath after mild exercise?*
3) Any recent changes to your medication for your heart condition?*
4) Have you ever had stents placed? (When?)*
5) Have you ever had bypass surgery? (When?)*
6) Have you ever had a heart attack? (When?)*
d) Seasonal allergies/ hay fever*
e) Sinus trouble*
1) Have you ever been hospitalized for your asthma?*
2) What triggers your asthma?*
If yes, what type:
h) Hepatitis A, B, or C or other liver dysfunction diseases?*
i) Thyroid problems*
j) Respiratory problems, emphysema, bronchitis, etc*
k) Arthritis or painful, swollen joints including jaw joint (TMJ)*
l) History of sleep apnea*
If yes, do you use a CPAP machine?*
m) Stomach or GI ulcers*
n) Reflux disease (GERD)*
o) Kidney trouble*
q) Persistent cough or cough that produces blood*
r) History of CVA or stroke*
s) History of TIA’s (ministrokes)*
t) Epilepsy or neurological disorder*
1) What was the treatment?*
2) Have you ever had other tumors or growths in the head neck region?*
3) Treated or removed?*
4) Have you ever had radiation therapy to the head, neck, or jaw?*
5) If so, who is your radiation oncologist?*
v) Any diseases, including HIV, drug or transplant operation that has depressed your immune system*
12) Have you ever had abnormal bleeding?*
13) Do you have a family history of abnormal bleeding (Vonwillebrand Disease, hemophilia)*
14) Do you have any blood disorder such as anemia?*
15) Are you allergic to or have you had a reaction to:
Penicillin or antibiotics*
Barbiturates or sleeping pills*
Codeine or other narcotics*
Latex or rubber products*
*Please note avocados, bananas, and kiwi may indicate potential for a latex allergy*
16) Have you had any serious trouble associated with previous dental treatment?*
17) Do you have any other condition or disease you think the doctor should know about?*
18) Do you smoke or chew Tobacco?*
19) Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you?*
20) Do you wish to talk with the doctor privately about anything?*
Are you pregnant or trying to become pregnant
Do you experience excess bleeding with your menstrual period?
Are you nursing?
Are you taking birth control pills?
I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.
4 Fairfield Dr Queensbury, NY 12804
Hours: Mon–Fri: 8 a.m.–5 p.m.
458 Maple Ave Saratoga Springs, NY 12866
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