PATIENT INFORMATION

PATIENT REGISTRATION

FREQUENTLY ASKED QUESTIONS

PATIENT INFORMATION

1. SCHEDULING

 

We are open Monday - Thursday from 8:00am to 4:30pm and Friday from 8:00am to 3:00pm.

 

We will schedule your appointment as promptly as possible. If you have pain or an emergency situation, please let us know as soon as possible and every attempt will be made to see you that day.

 

Dr. Liao will try her best to stay on schedule to minimize your waiting. However, due to the fact that this is a surgery office, various circumstances may lengthen the time allocated for a procedure. Emergency cases can also arise and cause delays. We appreciate your understanding and patience in the event that your appointment is delayed.

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2. FIRST VISIT

 

Your first appointment with Dr. Liao will be a consultation appointment. During this appointment, you may be discussing the following:

  • Your diagnosis
  • Nature of the procedure
  • Risks and benefits of the procedure
  • Alternative treatment to the procedure

 

Please assist us by providing the following at the time of your consultation appointment:

  • Referral slip
  • X-ray (if applicable)
  • List of medication you are currently taking
  • Dental and medical insurance card

 

You may choose to fill out the patient registration and health information here on our website. This form will be automatically sent to our office. You may also choose to print, fill out and bring the form to our office. This will save you time at the office and allow us to help process your insurance claim.

 

If you are a minor or a patient not financially responsible, you must be accompanied by a parent or guardian at the time of consultation visit, unless prior arrangements have been made.

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3. FINANCIAL INFORMATION

 

We are in contract with the following insurance companies including: Delta Dental, Metlife, Guardian, Cigna, United Concordia, and Principal. This means that we do have contracted fees with these companies. If we are not contracted with your insurance, the fee is decided by our office. The fee used would be the usual and customary rates (UCR): Our fees reflect our commitment to the quality our patients deserve and are considered usual and customary for the area, regardless of any insurance company’s determination.

 

Insurance: Insurance is a contact between you and your insurance company. As a service to our patients, we will bill your insurance company for you. It is not always possible for our office to become familiar with the details of every dental plan it encounters, and/or what is excluded from your dental plan. We will contact your insurance to obtain dental benefits and give you an estimate of fees at the time of your consultation. Ultimately the patient is responsible for knowing what is covered and what is excluded from his/her dental plan. The information we give you is an estimate, not a guarantee of benefits. Once we have received payment from your insurance company, if it is difference from our original estimate, you will be refunded or billed accordingly.

 

Payment options: Visa/Mastercard, Discover and American Express. Cash and check payments. We also offer CareCredit, an outside finance company that offers interest free payments for up to 12 months. There will be a $25.00 charge for all returned checks.

 

If the patient is a minor (under the age of 18), the parent accompanying the child is responsible for payment, unless prior arrangements have been made.

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4. PRIVACY POLICY

 

Our Notice of Privacy Practices form presents the information that federal law requires us to give our patients regarding our privacy practices. Click here to download the Notice of Privacy Practices as a PDF.

 

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PATIENT REGISTRATION

Please fill out the following information below to register online. If you prefer, you may also download a PDF version of the registration & health history form to print and fill out to bring with you to your appointment.

 

 

Parkside Oral Surgery & Implant Center

PATIENT INFORMATION

First Name:   Street Address:
Middle Initial:   City:
Last Name:   State:
Sex: Male Female   Zip Code:
Birth Date:   Home Tel. #:
Social Security #:   Work Tel. #:
Driver's License #:   Mobile Tel. #:
Email Address:      
         
Employer/Occuptation/School:      
         
Have you or a family member been a patient in this office before?      
Yes, name:      
No      
Check here if this patient has a legal guardian or parent

PARENT/GUARDIAN INFORMATION

 

Because the patient is a minor, or has a legal guardian/parent, please fill in the information for the responsible parent/guardian of the patient below.

 

Name:   Street Address:
Employer/Occuptation/School:   City:
Relationship to Patient

Father Mother

  State:
  Other   Zip Code:
      Home Tel. #:
      Work Tel. #:
      Mobile Tel. #:
         
If the patient's parents are divorced, what are the legal custody arrangements? Joint Sole
 

BILLING INFORMATION

 

Please enter the billing name and address of the responsible person.
Same as Patient
Same as Parent/Guardian
Name:   Street Address:
Contact Phone #:   City:
Relationship to Patient Father Mother
Other
  State:
      Zip Code:
         

DENTAL INSURANCE INFORMATION

Primary Dental Insurance

Policy Holder's Relationship: Other:
Policy Holder's Name:
Policy Holder's SS# or ID#:
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Group or Policy #:
Union or Local #:

 

Secondary Dental Insurance

Policy Holder's Relationship: Other:
Policy Holder's Name:
Policy Holder's SS# or ID#:
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Group or Policy #:
Union or Local #:

MEDICAL INSURANCE INFORMATION

Policy Holder's Relationship: Other:
Policy Holder's Name:
Policy Holder's SS# or ID#:
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Group or Policy #:
Union or Local #:

DENTAL/MEDICAL HISTORY

Name of Dentist:
Name of Orthodontist:
Name of Physician:
Who may we thank for referring you?
Kaiser ID #
Preferred Pharmacy:
Pharmacy phone #:
In case of Emergency, please notify:
Phone #:

HEALTH HISTORY

Chief Dental Complaint Today:
Are you in good health? Yes
No
Has there been any change in your general health in the past year? Yes
No
Date of last physical exam:
Are you now under a physician's care for a particular problem? Yes
No
Have you ever had any serious illnesses, operations or hospitalisations? Yes
No
Please describe:
Height: Weight:

HEALTH HISTORY

Please indicate if you have, or have had, any of the following:
Rheumatic Fever or Rheumatic Heart Disease
Congenital Heart Disease
Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Sugery, Pacemaker)
Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)
Seizures, Convulsions, Epilepsy, Fainting or Dizziness
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion, or Tendency to Bruise Easily
Liver Disease (Jaundice, Hepatitis)
Kidney Disease
Diabetes
Thyroid Disease (Goiter)
Arthritis
Stomach Ulcers or Colitis
Glaucoma
Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)
Radiation (X-ray) treatment for Cancer
Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth
Sinus or Nasal Problems
Any disease, drug or transplant operation that has depressed your immune system

 

HEALTH HISTORY

Please indicate if you are using any of the following:
Antibiotics   Steroids (Cortisone, etc.)
Anticoagulants (Blood Thinners)   Tranquilizers
Aspirin or drugs such as Motrin, Aleve, Ibuprofen   Insulin or Oral Anti-Diabetic drugs
High Blood Pressure medications   Digitalis, Inderal, Nitroglycerin or other heart drugs

 

Are you taking or have you ever taken Bisphosphonates (Fosamax or Actonel for osteoporosis, or chemotherapy for multiple myeloma, etc.)?
YesNo
 
Please list any and all medications taken, including prescription medications, over-the-counter medications, herbal or holistic remedies, vitamins, or minerals:
None

HEALTH HISTORY

Please indicate if you are allergic to or have had an adverse reaction to any of the following:
 
Local Anesthesia (Novocaine, etc.)
Penicillin or other antibiotics
Sedatives, Barbiturates
Aspirin or Ibuprofen
Codeine or other pain killers
Latex or Rubber Products
Other allergies or reactions? Please list
Do you smoke or chew Tobacco? Yes
No
How much per day?
Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care we provide you? Yes
No
Have you had any serious problems associated with any previous dental treatment? Yes
No
Have you or an immediate family member had any problem associated with intravenous anesthesia? Yes
No
Do you have any other disease, condition or problem not listed above that you think the doctor should know about? Yes
No
Please describe:
 
For Women Only
Are you Pregnant, or is there any chance you might be Pregnant? Yes
No
Are you nursing? Yes
No
If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

FREQUENTLY ASKED QUESTIONS (FAQ)

  • Information for most common procedures

    Untitled Document

     

    Administration of Anesthesia

     

     

    Click here to view more information on the Administration of Anesthesia.

     

    Wisdom Teeth Extraction

     

     

    Click here to view more information on Wisdom Teeth Extraction.

           

    Frenectomy

     

     

     

     

    Dental Implant Surgery

     

     

    Click here to view more information on Dental Implant Surgery.

     

  • Pre-Operative Instructions

     Pre-Operative Instructions

         Please Read Carefully

     

    All Patients having General Anesthesia or Sedation:

     

    ________ DO NOT smoke, eat, or drink, anything INCLUDING WATER, for 6 hours prior to your surgery. Foods, liquids, even water could end up in your lungs during surgery and be life-threatening. If you are instructed to take medication prior to your appointment, do so with a very small sip of water only. Eat a light, easily digestible meal the evening before your surgery.

     

    ________You must have a responsible adult accompany you to our office, wait during your procedure and drive you home.  It is preferable that this person remain with you at home for 6 hours after your surgery to take care of you. You MAY NOT drive a car or take public transportation after your procedure for 24 hours.

     

    _________Please wear short-sleeved shirt and loose, comfortable clothing. We will be placing heart and blood pressure monitors, and will need easy access to your upper arms. Please remove contact lenses prior to surgery and DO NOT wear any makeup or jewelry of any kind. All piercings must be removed PRIOR to your arrival to the office.  Also remove all nail polish.

     

    ________If you develop symptoms of a head or chest cold, or there are any changes in your health or medical history prior to your surgery, please call our office immediately.

     

     

    Please be sure you are comfortable with these instructions, and understand them thoroughly.

    Failure to comply with these instructions may result in cancellation of your appointment.

     

    We have reserved your appointment time specifically for you. Appointments to be cancelled must be done with at least 24 hours notice in order to avoid a cancellation fee.  Please also note that if you are 15 or more minutes late to your appointment, you may be rescheduled.

     

    Please have some ice packs (frozen bags of peas/corn are okay) and soft foods (yogurt, macaroni & cheese, oatmeal, mashed potato) ready at home before surgery. The patient will need to rest the whole day after surgery, it would be nice to have some books and DVDs ready too!

     

     

    Click here to download instructions as a Word document.

     

     

     

  • Post-Operative Instructions

     Post-Operative Instructions

     

     

     

     

     

     

PARKSIDE ORAL SURGERY

& IMPLANT CENTER

 

2525 Santa Clara Ave

Alameda, CA 94501

CONTACT

 

 

510.865.1114

info@parksideoralsurgery.com

 

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Parkside Oral Surgery & Implant Center. All Rights Reserved.