Virtual Consultation Form

Please complete the following form and click "Submit Form." A member of our team will contact you shortly!

Patient Information

Patient Name: First Name

Last Name

Patient Address

City

State

Zip Code

Patient Gender

Male Female

Patient Date of Birth

Email Address

Cell Phone

Home Phone

Work Phone

Driver's License

Social Security Number

We will need your SSN to verify dental and/or medical insurance

Marital Status

Single Married Divorced Widowed

Employment

Employed Unemployed Disabled Retired Student

Current Employer

Current University/College

Primary Care Provider

Primary Care Provider Phone Number

General Dentist

Type 'n/a' if you are not currently under the care of a general dentist.

Preferred Pharmacy

Preferred Pharmacy Phone

Responsible Party

Is the responsible party different than the patient or is the patient a minor?

Yes No

First Name of Person Responsible for Account

Last Name

Relationship to Patient

Responsible Party Date of Birth

Is address same as patient?

Yes No

Address

City

State

Zip Code

Responsible Party Employer

Responsible Party Primary Phone Number

Responsible Party Secondary Phone Number

Emergency Contact

First Name

Last Name

Phone

Relationship to Patient

Insurance Information

Do you have medical and/or dental insurance?

Yes No Yes, but I have already provided this information to the office

Dental Insurance Information

Insurance Company

Insurance Company Phone Number

Insurance Company Address

City

State

Zip Code

Subscriber ID

Subscriber's Social Security Number

Group Number

Subscriber's First Name

Last Name

Subscriber's Date of Birth

Relationship to Patient

Do you have a secondary dental insurance?

Yes No

Secondary Dental Insurance Information

Insurance Company Phone Number

Insurance Company Address

City

State

Zip Code

Subscriber ID

Subscriber's Social Security Number

Group Number

Subscriber's First Name

Last Name

Subscriber's Date of Birth

Relationship to Patient

Medical Insurance Information

Insurance Company

Insurance Company Phone Number

Insurance Company Address

City

State

Zip Code

Subscriber ID

Subscriber's Social Security Number

Group Number

Subscriber's First Name

Last Name

Subscriber's Date of Birth

Relationship to Patient

Do you have a secondary medical insurance?

Yes No

Secondary Medical Insurance Information

Insurance Company

Insurance Company Phone Number

Insurance Company Address

City

State

Zip Code

Subscriber ID

Subscriber's Social Security Number

Group Number

Subscriber's First Name

Last Name

Subscriber's Date of Birth

Relationship to Patient

Chief Complaint

Please briefly describe the main reason you are seeking dental care today:*

Medical History

What is your height (in feet and inches)?

What is your weight in pounds?

Do you have any medical conditions that require you to take an antibiotic before dental treatment (ie certain heart conditions, or recent joint replacement surgery)?

Yes No

Are you presently taking a blood thinner other than 81mg Aspirin? (ie Coumadin, Warfarin, Jantoven, Plavix, Clopidogrel, Effient, Prasugrel, Aggrenox, Xarelto, Eliquis, Pradaxa, Dabigatran, etc)

Yes No

Have you ever had any of the following medical conditions?

AIDS/HIV

Yes No

Allergies

Yes No

Anemia

Yes No

Angina (chest pain)

Yes No

Arthritis

Yes No

Artificial Heart Valve

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Diabetes

Yes No

Dizziness

Yes No

Drug Addiction

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Excessive Bleeding

Yes No

Fainting

Yes No

Glaucoma

Yes No

Heart Conditions

Yes No

Heart Murmur

Yes No

Heart Surgery

Yes No

Hepatitis

Yes No

High Blood Pressure

Yes No

HPV (Human Papilloma Virus)

Yes No

Jaundice

Yes No

Jaw Joint Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Nervousness/Depression

Yes No

Pacemaker

Yes No

Radiation (head/neck area)

Yes No

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Seizures

Yes No

Sinus Problems

Yes No

Sleep Apnea

Yes No

Stomach Problems

Yes No

Stroke

Yes No

Thryroid Disease

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Osteoporosis

Yes No

Any other medical problems that were not listed?

Do you smoke or chew tobacco?

No Daily Weekly Less Former User

Alcohol Use

No Daily Weekly Less Former User

Are you currently taking supplements or prescription medication?

Yes, I am. I do not take any medications.

Please list EVERY medication that you take. Please include ALL prescription medications and over-the-counter medicaions.

Do you suffer from any known medication allergies?

Yes No

Please list in greater detail your specific allergy and allergic reactions.

Have you had any surgeries in the past 5 years?

Yes No

Previous Surgical History

If Other, please specify:

Family History

If Other, please specify:

Financial Agreement

We share your concerns regarding the cost of health care. We believe that you, our patients, expect and deserve the highest quality care we can provide at a reasonable cost. While we take advantage of every possible avenue to keep costs down, we are committed to not sacrificing quality for less expensive care. With this in mind, we would like to share some information with you about our financial policy. We want you to be comfortable with us regarding our services and our financial policies. Many people are under the impression that if they have insurance, it is the insurance company who owes the doctor for services. Please keep in mind, the insurance contract is between the patient and the insurance company. The patient is responsible for the bill, regardless of insurance coverage determination. As a courtesy to our patients we are happy to bill your primary insurance for you, however the responsibility for payment remains with the patient (or the insured party). At the time of surgery patients are required to make full payment based upon benefit information obtained from your insurance company., including, but not limited to, your deductible, coinsurance, percentage and co-pays. If your insurance pays more than expected a refund will be issued to you. In spite of that statement, we have found many plans, may cover less depending on their established "usual and customary" when setting fee limitations on services. Please be aware some insurance companies will pay a claim percentage based on their "usual and customary" fees not our actual charges. We allow 60 days for your insurance carrier to make payment. After this time all inquires (follow up) on payments due become your responsibility.

Medicare: Dr . Harry Mack & Dr. Ryan Thomas are "non- participating" providers under the medicare program. Medicare patients are personally responsible for full payment for their services. Patients without insurance are required to make full payment at the time of service unless other arrangements are established PRIOR to the day of your appointment. In addition to credit card payments, our office accepts care credit, which allows patients to finance their treatment through a third party.

I understand that if my insurance carrier deems the treatment as not Medically Necessary/ Subject to Review/ Non Covered as defined in my policy, I am responsible for the Total Treatment Estimate. I agree to pay all cost of collection and any attorney fees incurred by Dr. Mack and Dr. Thomas or their assigns. I understand and agree to all financial information. For individuals with insurance your signature below authorizes your insurance benefits to be paid directly to Dr. Mack and Dr. Thomas. You are financially responsible for any balance due. It authorizes the doctor to release any information required for payment and processing the claim.

I have read and agree with the above financial policy.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for the purpose of treatment, payment, and healthcare options. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms for future care or treatment. it also includes billing documents for those services.

Example of use of your Health Information for Treatment Purposes: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of use of your health information for Payment Purposes: We submit a request for payment to your health insurance company. The health insurance company requests the information from us regarding medical care given. We will provide information to them about you and the care given.

Example of use of your health information for Healthcare Operations: We obtain services from our insures and other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

YOUR HEALTH INFORMATION RIGHTS: The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to: 1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request granted. 2. Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by delivering the request in writing to our office. 3. Appeal a denial of access to your protected health information except in certain circumstances. 4. Request that your healthcare record be mended to correct incomplete or incorrect information by delivering a written request to our office. 5. File a statement of disagreement if your amendment is declined, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information. 6. Obtain an accounting of disclosure of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of the information for treatment, payment, or operation, or disclosures made to family members or friends in the course of providing care. 7. Request that communication of your health information be made by alternate means or at an alternate location by delivering the request in writing to our office; and, revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact Dr. Harry Mack or Dr. Ryan Thomas in person or in writing, during normal business hours. They will provide you with assistance on the steps to take to exercise your rights.

OUR RESPONSIBILITIES: The practice is required to: 1. Maintain the privacy of our health information as required by law. 2. Provide you with notice of our duties and privacy practice as to the information we collection and maintain about you. 3. Abide by the terms of this notice. 4. Notify you if we cannot accommodate a requested restriction or request; and, accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions. In our privacy policy and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our notice. You are entitled to receive a copy of the revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.

TO REQUEST INFORMATION OR FILE COMPLAINT: If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Dr. Harry Mack or Dr. Ryan Thomas at our office. Additionally, if you believe your privacy rights have been violated, you may file a written complaint to our office by delivering the written complaint to Dr. Harry Mack or Dr. Ryan Thomas. You may also file a complaint by contacting the Secretary of Health and Human Services at: Department of Health and Human Services, 61 Forsyth Street, S.W., Atlanta, GA 30303, (404) 562-7889. We cannot and will not require you to waive your rights to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice. We cannot and will not retaliate against you for filing a complain with the Secretary.

OTHER DISCLOSURES AND USES: Notification: Unless you object, we may use or disclose your protected health information to notify a family member, personal representative, or other person responsible for your care, about your location, and about your general condition or your death. We permit disclosure decedent's wishes. The following uses and disclosures require authorization: (a) Many uses of psychotherapy notes; (b) Uses and disclosures of protected health information (PHI) for marketing; (c) Sale of PHI.

APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voicemails, postcards, letters, e-mails, texts, or other similar mobile device communications.)

MARKETING HEALTH RELATED COMMUNICATIONS: We will not use your health information for marketing communications without your written authorization.

COMMUNICATION WITH FAMILY: Using our best judgment, we may disclose to a family member or other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment of such care if you do not object or in an emergency.

FOOD AND DRUG ADMINISTRATION (FDA): We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects ot post-marketing surveillance information to enable product recalls, repairs, or replacements.

WORKERS COMPENSATION: If you seek compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

PUBLIC HEALTH: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

IMMUNIZATIONS: We permit disclosure of immunization to schools if required by law.

ABUSE AND NEGLECT: We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

CORRECTIONAL INSTITUTIONS: If you are an inmate of a correction institute, we may disclose to the institute or its agents your protected health information necessary for your health and the health and safety of other individuals.

LAW ENFORCEMENT: We may disclose your personal health information for the law enforcement as required by law, such as when required by court order or in cases involving felony prosecutions or the extent an individual is in the custody of law enforcement.

HEALTH OVERSIGHT: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities your consent or as directed by the proper court order.

NOTIFICATION OF BREACH OF UNSECURED HEALTH INFORMATION: Our policy is to encrypt our electronic files containing your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your un-encrypted health information, we will notify you of the breach.

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information over the last 6 years or such shorter time as you may specify. That accounting would not include disclosures made for the purpose of treatment, payment, or healthcare operations unless we maintain your health record electronically, in which case, after January 1, 2011, we may need to provide you with an accounting of treatment, payment, or healthcare operations disclosures for no more than 3 prior years, but not including any treatment, payment, or healthcare operations disclosures prior to January 1, 2011. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

ELECTRONIC NOTICE: If you receive this Notice on our website or by electronic mail, you have the right to request a paper copy of this Notice. You may make such a request in writing.

OTHER USES: Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

WEBSITE: If we maintain a website that provides information about your entity, this Notice will be n the website. Effective April 1, 2003.

I have read and agree with the above Notice of Privacy Practices

Authorization to Release Information

Purpose: To obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself. I authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.

Add authorized person(s)

Short text

Virtual Consultation Form

Patient Information

Responsible Party

Emergency Contact

Insurance Information

Dental Insurance Information

Secondary Dental Insurance Information

Medical Insurance Information

Secondary Medical Insurance Information

Chief Complaint

Medical History

Have you ever had any of the following medical conditions?

Previous Surgical History

Family History

Financial Agreement

Notice of Privacy Practices

Authorization to Release Information

NASHVILLE ORAL SURGERY