Step 1 of 6 16% Date Date Format: MM slash DD slash YYYY General Patient InformationPatient first name*Patient middle initialPatient last name*Date of birth* Date Format: MM slash DD slash YYYY AgeSexAddressAptCityStateColoradoAlabamaAlaskaArizonaArkansasCaliforniaConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipPrimary phone number*Secondary phone numberEmail Social security numberDrivers license state and numberEmployerWork phone numberEmployer addressReferring doctorPharmacy you useLocation or cross streets of pharmacy IF THE PATIENT IS A MINOR: Is the patient a minor?YesNoName of guardian or parentRelationship to patientAddress of guardian or parentCity of guardian or parentState of guardian or parentColoradoAlabamaAlaskaArizonaArkansasCaliforniaConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of guardian or parentPhone number of guardian or parentAlternate phone number of guardian or parentEmail address of guardian or parent Social security number of guardian or parentDrivers license number and state of guardian or parentEmployer of guardian or parentWork phone number of guardian or parentEmployer address of guardian or parentEMERGENCY CONTACT:Name of emergency contactPrimary phone number of emergency contactEmergency contacts relationship to patient INSURANCE INFORMATION:Dental insurance companyPhone number of dental insurance companyAddress of dental insurance companyName of dental insuredSocial security number or ID number of dental insuredDate of birth of dental insured Date Format: MM slash DD slash YYYY Employer of dental insuredGroup ID number of dental insuredMedical insurance companyPhone number of medical insurance companyAddress of medical insurance companyName of medical insuredSocial security number or ID number of medical insuredDate of birth of medical insured Date Format: MM slash DD slash YYYY Employer of medical insuredGroup ID number of medical insured Medical HistoryHeightWeightALLERGIES & MEDICATIONSPlease list all known allergies:Please list all current medications including non-prescription or homeopathic or natural remedies and vitamins:Do you have or have you had any of the following diseases or problems?Heart murmurYesNoHeart diseaseYesNoRheumatic feverYesNoChest painYesNoHeart arrhythmiaYesNoHigh blood pressureYesNoAnkle swellingYesNoShortness of breathYesNoPneumoniaYesNoTuberculosisYesNoOther lung diseaseYesNoAsthmaYesNoChronic coughYesNoEmphysema or COPDYesNoObstructive sleep apneaYesNoSinus troubleYesNoFainting spellsYesNoUlcers or colitisYesNoAcid refluxYesNoHepatitis or jaundiceYesNoOther liver diseaseYesNoDiabetesYesNoHigh blood sugarYesNoLow blood sugarYesNoProblems urinatingYesNoKidney problemsYesNoHeavy snoringYesNoLatex allergyYesNoAnxiety or depressionYesNoAnemiaYesNoHemophiliaYesNoOther blood disorderYesNoEpilepsy or seizuresYesNoStrokeYesNoThyroid diseaseYesNoBack injury or painYesNoNeck injuryYesNoArthritisYesNoGlaucomaYesNoTumor or cancerYesNoAIDS or HIV positiveYesNoBlood transfusionYesNoOther disease or condition not listedYesNoAre there any other conditions or medical problems your doctor should be aware of?Referred byReason for referralDentistDo you wear contact lenses?YesNoDo you take blood thinners such as Coumadin or Warfarin or Plavix or Effient?YesNoDo you take aspirin?YesNoHave you ever had a total joint replacement such as a hip or knee or shoulder?YesNoDo you drink alcohol on a regular basis?YesNoDo you regularly use marijuana?YesNoDo you use any other recreational drugs?YesNoDo you have a history of alcohol or substance abuse?YesNoHave you or a family member ever had any problem with general anesthesia?YesNoDo you snore at night or have problems breathing through your nose?YesNoHave you ever been treated with prednisone or other steroids for greater than 2 weeks at a time?YesNoAre you being treated with or have you ever taken Aredia or Zometa for breast cancer chemotherapy?YesNoAre you or have you ever taken Fosamax or Actonel or Reclast or Boniva or Prolia for Osteoporosis?YesNoDo you or have you previously smoked or chewed tobacco?YesNoIf yes how much?If you previously smoked how long was the duration?Have you been in the military?YesNoIf yes do you have symptoms of PTSD?YesNoWOMEN ONLYAre you pregnant or trying to conceive?YesNoAre you nursing?YesNoAre you on birth control pills?YesNo Financial Policy Dr. Kunkel and his staff welcome you to our office, and we thank you for choosing us as your health care provider. We are committed to delivering your care in the most considerate and professional manner. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any evaluation or treatment. Our Financial Policy: Our office has established procedures that maintain quality care and reasonable cost for our patients. Charges for your exam, x-rays and any other diagnostic aids obtained during your first appointment are due at that time. These fees will be filed to your insurance. Any payments received by your insurance for these charges will be applied to your account if there is a current balance, or a refund will be issued to you. If your surgery is not covered by insurance, or if you desire to have your exam and treatment performed on the same day (i.e., emergency patients), we will require payment in full by cash, credit card, personal check, or cashier’s check prior to any treatment. The fees quoted are an estimate only. If the procedure proves to be more complex than anticipated, the fees will be adjusted accordingly. The stated fees will be honored for a period of 6 months. After that period, you may be required to be seen for an updated exam prior to surgery, which may be an additional cost. Your Insurance Coverage: As a courtesy to you, we will file your insurance claim, and we will accept payment of insurance benefits after your first visit. However, based on what your insurance company reports to us, we do require that your estimated portion, including any deductible of treatment, be paid at the time of surgery. If your insurance company has not paid your account in full within 60 days, the account will be due, and you will be sent a statement requiring payment of the balance within the next 10 business days. Once all insurance benefits are received, we will gladly reimburse you any overpayment. We must remind our patients that insurance is a contract between you and your insurance company to pay certain amounts for medical care. Your bill is a contract between you and your doctor and does not involve the insurance company, even when we file the insurance claim for you. In short, you are responsible for any and all charges not paid by your insurance carrier, and your financial obligation for payment is not dependent on insurance coverage. Regarding Managed Care Plans for which we are a participating provider, all co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan for which we are not a participating provider, refer to the above paragraph. If you have Medicare, you must sign a “private contract” showing you will be responsible for all charges. As a service to our patients, we are pleased to participate in the following credit plans: Care Credit and Lending Club. Usual & Customary Rates: Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary “schedule” of fees, which often bears no relationship to the current standard and cost of care in this area. Delinquent Accounts: All accounts that remain unpaid after the aforementioned period of time will be sent to our collection services. We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. We do ask you to be on time to your appointment. If you are late, your appointment may be rescheduled at the office’s discretion. This is for us to give you the best care possible. A service charge of $75.00 will be added if a surgery appointment is canceled less than 24 hours from the appointment. A service charge of $25.00 will be assessed on all returned checks. Should it become necessary for this office to employ an attorney to enforce payment for treatment rendered, the patient agrees to pay reasonable attorney’s fees, court costs, and interest incurred for such enforcement. Thank you for taking your time to review our financial policy. Should you have any questions or concerns, we would welcome the opportunity to discuss them with you. Your signature below indicates that you have read, understood, and agreed to this financial policy and that you will be responsible for payment in full of this account. Authorization to Release Health Care Information The top part of this page is optional for patients over the age of 18. Due to the federal privacy laws, our office is not allowed to discuss any information regarding your medical records, account, etc., with anyone other than you directly. You will want to complete this form if you anticipate anyone calling on your behalf. This form does not apply to any physicians discussing treatment with each other. I request and authorize Dr. Kunkel to release health care information of the patient named above to the following individual(s): Name 1Relationship 1Name 2Relationship 2I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know that canceling this authorization would not prohibit any release of information by the doctor or practice in reliance on my original authorization. Once my doctor gives out the information that I want released, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information. The office of Dr. Kunkel may be leaving messages at the home number or the contact number provided.* *If you do not wish to have a message left for you, please let us know. The office of Dr. Kunkel reserves the right to modify the privacy practice outlined in the notice located in the reception area. A copy of the Notice of Privacy Practices for Dr. Kunkel has been made available to me, and I have had the opportunity to read the information. *By state law, if you are prescribed a controlled substance, your identifying information will be entered into a statewide database of controlled substance prescriptions.Michael Kunkel, DDS Dr. Kunkel does not participate in the Medicare program because: Most dental services, including oral surgery, are not a covered benefit; Medicare provides very low payments for the few oral surgery services covered; Medicare delays the processing of claims submitted. Dr. Kunkel does provide his services to Medicare-eligible patients. However, Medicare requires that its insured person enters into a “private contract” with providers who are not contracted with Medicare. If you choose to have Dr. Michael Kunkel provide services, you must enter into said “private contract.” This contract is between Dr. Kunkel and the patient. Oral surgery services will be provided according to the treatment plan agreed upon between Dr. Kunkel and the patient (or his/her legal representative). Dr. Kunkel will charge the established fees for these services. Payment by the patient will be in accordance with Dr. Kunkel’s financial policy. By submitting this form, the patient or his/her representative signifies his/her agreement with the above terms.