LYELL R. HOGG, DDS
CHRISTOPHER KEPROS, DDS
AARON KOTECKI, DDS

General Patient Information

Sex: 
Date Of Birth:
Have you ever been a patient of our practice? 

Person Legally Responsible For Account (If Under 18)

 Who will be responsible for your account? 
(If self, skip next section.)
DOB:
 

Insurance Information

 

 Primary Dental Insurance

DOB:
Insurance Card Address (located on the back of your card)

Primary Dental Insurance Card Images:
 

 Primary Medical Insurance

DOB:
Insurance Card Address (located on the back of your card)

Primary Medical Insurance Card Images:
 

 Secondary Dental Insurance

DOB: 
Insurance Card Address (located on the back of your card)

Secondary Dental Insurance Card Images:
 

 Secondary Medical Insurance

DOB: 
Insurance Card Address (located on the back of your card)
 
Secondary Medical Insurance Card Images:



 


Financial Agreement

The following financial arrangements are available.

Please indicate your choice of payment by checking Option A, B, or C.

We appreciate your understanding and cooperation in completing the following information. If you have any questions concerning

our financial policies, please do not hesitate to ask for our office manager.
 

Payment is expected at time of treatment by

 

If we are able to predetermine insurance coverage, you may know an estimate of your financial responsibility prior to surgery. If

not, the exam fee cost and 20% of the total surgery/anesthesia/radiograph fee is due at the time of service. After your

insurance company has made payment, the remainder of your balance is considered payable in full by you at that time. Options A

(above) or C (below) are available to pay your balance.

 

Any overpayment by you or your insurance company will be refunded after the account has been paid in full.

 

Note: 


FOR PATIENTS IN MANAGED CARE PLANS (INCLUDING MEDICAID [TITLE XIX]) WELLNESS

  1. A copayment as directed by your managed care plan is required at the time of service.
  2. Allowable charges for services not covered by your managed care plan are your responsibility. Options A (above) and C (below) are available for payment of those fees.

  3. Medicaid (Title XIX) Wellness will not pay for your Panorex X-ray if one has been taken in the last 5 years. You will be responsible.
     

Patients wishing to finance treatment fees may be eligible for payment plans/financing through CareCredit. Please request details from the receptionist or office manager.

Please Note

  1. If 60 days have passed since your last payment, your account may be turned over to legal counsel and/or a collection agency for collection.
  2. Legal papers will be filled (your account will be charged a $35.00 processing fee) with a collection agency, in a further effort to collect on your account.
  3. A processing fee will be assessed to all accounts with returned checks.

  4. Accounts with returned checks may be turned over to legal counsel and/or a collection agency for collection.


 

As a courtesy to our patients, we will file insurance claims for you with the information you provided; however, our professional services are rendered to you and not to the insurance company. Therefore, you are directly responsible to us for the cost of your treatment. Your signature below hereby assigns all benefits to North Iowa Oral Surgery & Dental Implant Center that would otherwise be payable to you under the dental expense provision of the above-named dental insurance policies.




Health History

 
   
Today's Date:
 
 
 
 
 
 
 
​​​​​​Patient Height:

Patient Weight:

For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential.
 
1. Are you under the care of a physician?
 
If so, for what condition?
 
2. The name and phone# of your physician ​​​​
3A. Are you taking any medicine(s) including non-prescription, homeopathic, natural remedies, or diet pills?
If so, please list:
3B. Do you take or have you ever taken or been given any of the following medications? (Check those that apply.)
 

4. Are you allergic to or have you had an allergic reaction to any of the following?
      
 
Local anesthetics


Penicillin or antibiotics


Barbiturates or sleeping pills


Aspirin or ibuprofen
Iodine


Codeine or other narcotics


Latex or rubber products


Other
 5. Have you had any surgery, serious illness, or hospitalization in the past?
 If so, please list:
 6.  Have you or any family members had any serious reactions to IV sedation or general anesthesia? 
 If so, explain:
 7. Do you have or have you had any of the following diseases or problems?
Damaged Heart Valves. Artificial Valves, or Heart Murmur


History of Snoring, Sleep Apnea, or Use of CPAP


Rheumatic Heart Disease


Heart Attack, Heart Surgery. or Irregular Heartbeat


High Blood Pressure

 
 Asthma, Hay Fever, or Allergies 


Emphysema, Bronchitis. Etc 


Sinus Trouble


Tuberculosis
 Stomach Ulcer or Frequent Heartburn


Liver Trouble (Hepatitis, Jaundice, or Liver Disease)


Kidney Trouble 


Diabetes


Thyroid Problems


Arthritis or Painful, Swollen Joints Including Jaw Joint (TMJ)


Seizures (Epilepsy), Stroke, or Neurological Disorder 


Any Disease, Drug, or Transplant Operation that has Suppressed your Immune System
​​​​​

Have you taken any steroid medications in the past two years
 8. Do you have any blood disorders?
Anemia


Abnormally prolonged bleeding (e.g., hemophilia) 
Have you ever required a blood transfusion?


Are you taking any blood thinners? 
​​​​​
9. Do you have any artificial joints (hip, knee, shoulder. etc.)?
10.  Have you ever been treated for glaucoma?
11. Have you ever had treatment for a tumor or cancer?
Radiation therapy involving the mouth, face, or neck 
Chemotherapy
12. Do you smoke, or have you ever smoked?
If yes, how much?
For how long?
year(s)
Quit when?
13. Have you ever been treated for alcohol or other substance abuse?
If yes, for what?
When?
14. Have you ever or do you currently use any recreational/illicit drugs? 
If yes, what?
 15. Have you had a cold, flu, sore throat, sinus infection, or other respiratory tract infection in the past week?
16. Do you have any other concerns or diseases you think the doctor should know about? 
 If so, explain:
 17. Do you wish to talk with the doctor privately about anything?

 Women Only

 Are you pregnant or trying to become pregnant? 
 Are you nursing (breastfeeding)?
 Are you taking birth control pills?

 
If you're using oral contraceptives, it is important to understand that antibiotics (and some other medications) interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance. 





 

 Acknowledgment of Receipt of Statement of Privacy Practices

 I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of North Iowa Oral Surgery & Dental Implant Center. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. 

North Iowa Oral Surgery & Dental Implant Center reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

 In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected healthcare information to the person(s) identified below. (I understand that the default answer is NO. Without indicating YES in answer to each individual question, personal protected healthcare information [PHI] cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
 Spouse Only:
Any Member of My Immediate Family (e.g., Spouse, Children, Siblings, etc.)
Any Member of My Extended Family (e.g., Parents, Grandchildren, etc.)
Other

 







By signing below you are confirming the General Patient Information and Health History has been filled out accurately and to the best of your ability. Your signature is also confirming that you have read and understood the Financial Agreement and Acknowledgment of Receipt of Statement of Privacy Practices and Additional Disclosure Authorization. 


 
Patient's (or Legal Guardian's) Signature:
(Click and drag mouse to sign, or press with finger for mobile devices)
Date:
Print Patient's (or Legal Guardian's) Name:
Relationship: