Please indicate any of the following problems that you are having:
Oral and Pharyngeal Cancer Checklist
Check all that apply:
Medical History and Information
Do you have or have you had any of the following diseases, medical conditions or procedures answer YES or NO to all:
Office and Patient Relationship
We are here to discuss any questions or concerns regarding our services. Successful treatment works best if there is a mutual understanding between the provider, staff and the patient.
It is important that you understand and agree to all treatment rendered understanding that treatment plans can change. When treatment changes you will be made aware prior to procedures being done.
I authorize the staff and the provider to perform any necessary services needed during diagnosis and treatment. I also authorize the release of any information needed to process insurance claims.
It is important that you understand all treatment rendered payment in full for all services rendered at the time of visit, unless other financial arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collections agency fees, interest charges and any other expenses incurred in collecting your debt.
I understand that if my treatment is beyond the scope of this office, I will be referred to the appropriate specialist that the provider recommends and my records would be forwarded to the specialist.
I understand the above information and guarantee this form was completed accurately to the best of my knowledge and I understand it’s my responsibility to inform the office of any changes to the information I provided.
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Patient or Parent/Guardian
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