PATIENT REGISTRATION

FEES AND PAYMENTS

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completions 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 at the top of the 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.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist named of the insurance benefits otherwise payable to me. I recognize and accept personal responsibility for any balance or fee not covered.

A.

B. HAVE YOU HAD OR DO YOU CURRENTLY HAVE

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

North Coast Oral & Maxillofacial Surgery Inc.

ORAL SURGERY POST OPERATIVE INSTRUCTIONS

Swelling, discomfort, and restricted jaw function are to be expected.

1. Remove gauze upon arriving home. Slight bleeding is expected and desirable. If bleeding is excessive, place a gauze or moistened tea bag over the wound and bite firmly for 1 hour with CONSTANT PRESSURE.
2. Take medication as prescribed. Do not drive, work, exercise or operate machinery while taking pain medication, and you may require assistance in walking.
3. Apply ice packs to jaw 20 minutes on/20 minutes off on the first day of surgery and the day after. On the third day, moist warm compresses can be used to reduce swelling. Keeping head elevated on two pillows will also help reduce swelling. Peak swelling can be expected 2-3 days after surgery.
4. Drink lots of liquids and eat soft foods.
5. On the day of surgery, do not rinse, spit, or drink through a straw. Spitting and rinsing will dislodge the clot.
6. The day following surgery, brush your teeth and use warm salt water rinses (1/2 teaspoon to a glass of warm water) after each meal and at bedtime.
7. Do not smoke the day of surgery.
8. Observe children after anesthesia — so they do not bite or chew their lip, cheek, tongue; or fall.
9. Antibiotics have been shown to decrease the effectiveness of Oral Contraceptives. Women on birth control pills are advised to take additional appropriate precautions.

PATIENTS PLEASE NOTE

1. You must be accompanied by a responsible adult driver for a general anesthetic.
2. Inform us of any allergy and past or present illness
3. Do not wear tight clothing and be sure your sleeve can be rolled up above your elbow
4. For General Anesthesia do not eat or drink anything eight hours before your appointment.
5. Do not wear any jewelry.
6. Pattern should bring complete list of current medications.