We appreciate the confidence you have shown our office by scheduling an appointment for an evaluation. Our mission is to provide you with the highest quality of health care. Good communication is essential for the best treatment results and we welcome any questions or comments you have regarding your treatment.
Before your appointment, please complete the enclosed patient health history form and bring it with you to your initial examination.
The estimated time of your new patient appointment will be 1.5 hours. If you need to cancel or reschedule your appointment, please notify our office at least 24 hours in advance!
If your dentist referred you to our office and you have had a recent panorex x-ray taken (within the last year) please bring a copy with you to your appointment or have a copy forwarded to our office. If you have been referred to our office for sleep apnea please bring a copy of your baseline sleep study or have the sleep center forward a copy prior to your appointment.
Our policy is to collect payment at the time of service. Please be prepared to pay for your initial appointment to our office. Our office accepts cash, check, or credit card at each office visit. We also offer monthly payment plans with no interest for thos who qualify. If you would like an estimated cost for this initial appointment please call our office. We cannot estimate your treatment cost prior to your initial appointment/exam until Dr. Walz has evaluated all your symptoms and we have a diagnosis.
We have two office locations one in Normal and one in East Peoria. See the reverse for a map with directions to both offices or visit our website. Internet maps such as Map Quest or Google can be helpful. However, most GPS systems DO NOT give accurate driving directions to 731 Sabrina Drive in East Peoria. If you need further help with directions please call our office.
Benefits for treatment of TMJ and Sleep Apnea are customarily filed under your major medical insurance policy. However, some dental plans also provide some coverage for TMJ. We will file your insurance claim for you to your dental or Medical insurance company for possible reimbursement. Once you have been seen in our office we will assist you in finding out what coverage is available under your plan and we can file a predetermination if necessary. )if you would like to find out what coverage is available prior to your first appointment we advise you read your policy carefully and call your insurance carrier to determine what your benefits, limitations or exclusions for TMJ or Sleep Apnea are under your policy. If you are enrolled in an HMO policy it may be required that you see your primary care physician first for a referral to our office. Please contact your plan administrator to see if a referral is needed for coverage.
Medicare Part B provides coverage for your initial consult and x-ray. We will submit your claim to Medicare, however, payment will be due at the time of service and the patient will be reimbursed from Medicare and their insurance company less any co-pays or deductibles. If you are enrolled in a Medicare replacement plan or Medicare HMO plan it may be required that you see your primary care physician first for a referral to our office. Please contact your plan administrator to see if a referral is needed for coverage.
East Peoria Office
From Peoria: East on 1-74 toward Morton. Take exit #98, Pinecrest Drive. Turn left onto Fahey Hollow Rd and go over the interstate. Turn left onto interstate frontage road, Sabrina Drive. The office is the Ist building on the right. We are the 1st awning/door, Suite A.
From BloomlNormal: Head west on 1-74 toward Peoria. Take exit #98, Pinecrest Drive. Turn right onto Fahey Hollow road. Turn left onto the interstate frontage road, Sabrina Drive. The office is the first building on the right. We are the 1st awning/door, Suite A.
We are located in the ISU area of Bloomington/Normal. From Interstate 55 take Bus-S I South (Main Street) which eventually turns into Kingsley when you past College Ave. Go past Kingsley Jr High on the right then one block south to Dale Street, turn left. Turn immediate left into Dale Kingsley Plaza. Our office is the last suite at the end of the parking lot, suite 4.
We look forward to seeing you at your upcoming appointment. If you need additional directions, please call our office.
Head, Neck & Facial Pain Questionnaire
This questionnaire was designed to provide important facts regarding your past and present medical history. Please take your time to fill out the form accurately as it will assist us in reaching a diagnosis and determine the source of your problem. Please sign and date the bottom of each page.
Using the guide below please find your chief complaints (the reason you are seeking treatment), list them in order with # 1 being the most important #2 the next important, etc.
Please list all medications you are currently taking:
Please list any Health professionals and treatments provided for this problem and all Health professionals you are currently seeing or are scheduled to see.
If you were involved in an accident or traumatic incident please complete this section:
(Please indicate dates on questions checked YES)
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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