PATIENT INFORMATION:
    WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT
    INSURANCE INFORMATION
    PRIMARY DENTAL INSURANCE COMPANY
    PRIMARY MEDICAL INSURANCE COMPANY
    HEALTH HISTORY
    To our patients: Although we primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
    HEALTH HISTORY CONT.
    PREGNANCY & BIRTH CONTROL
    Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.
    ARE YOU NOW TAKING
    ARE YOU ALLERGIC OR HAD A REACTION TO
    HAVE YOU HAD, OR DO YOU CURRENTLY HAVE
    HAVE YOU HAD, OR DO YOU CURRENTLY HAVE
    Conclusion
    SIGNATURES
    Verification

    I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

    Fees & Payments

    We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection cost, attorneys’ fees, and court costs.

    Release of Information

    This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

    Authorization for Service

    I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment.

    Notice of Privacy Practices

    I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this notice.

    Photograph and Publicity Release Form

    I give L. Stephen Vaughan, DDS, M.D., Inc. permission to use my likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of L. Stephen Vaughan DDS M.D. Inc. these uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release the L. Stephen Vaughan DDS M.D. Inc. and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I have read and understood this consent and release.

    *Option 1: I give my consent to L Stephen Vaughan DDS M.D. Inc. to use my name and likeness to promote on social media, its fiscal agent, and/or their activities.

    *Option 2: I give my consent to L Stephen Vaughan DDS M.D. Inc. to use only photos of my mouth (including but not limited to my teeth, tongue, cheeks, and gums) to promote on social media, its fiscal agent, and/or their activities. I do not give my consent to use my full face or my name to promote on social media, its fiscal agent, and/or their activities.

    *Option 3: I do not give my consent to L Stephen Vaughan DDS M.D. Inc. to use my name and likeness to promote on social media, its fiscal agent, and/or their activities.