Welcome to the CU School of Dental Medicine! On behalf of our faculty and staff, we welcome you to CU Oral and Maxillofacial Surgery. We are pleased you selected us for your dental care, and we look forward to your first appointment. To help ensure you have a positive experience, please keep the following in mind:

Arrive 20 minutes early for check-in procedures

CU Oral and Maxillofacial Surgery is located at the School of Dental Medicine on the 1st floor. See the enclosed map for directions and parking instructions

To cancel or reschedule your appointment, please call our office at least 24 hours prior to your appointment

Please bring the following items to your appointment (if applicable):

Completed patient forms (enclosed or can be found at www.ucdenver.edu/omfs)

Medical and dental insurance information

Photo ID

Current x-rays (your dentist may send them to sdm-omfsdfp@ucdenver.edu)

List of medications and dosage information Please bring your medical and dental insurance information with you to the consultation visit so we can expedite reimbursement. We will work hand in hand to maximize your insurance reimbursement for covered procedures. Services will be billed to either your medical or dental insurance based on the type of treatment you receive. If you do not have medical insurance and the treatment is considered medical, you will be required to pay out-of-pocket. If you do not have dental insurance and the treatment is considered dental, you will be required to pay out-of-pocket. Should you have any questions, please visit our website at www.ucdenver.edu/omfs or contact our office at 303-724-4672. We look forward to meeting you and serving your dental needs. Sincerely, CU School of Dental Medicine Oral and Maxillofacial Surgery Ryan Dobbs, DDS, MD Terry Su, DDS, MD

Updated 1.18.2017

Patient Information (Información del Paciente):

Legal Last Name (Apellido(s) completos)

Legal First Name (Nombre completo) MI

Preferred Name (Nombre preferido)

Permanent Address (Dirección permanente) Apt #:

City (Ciudad) State (Estado) Zip Code (Código Postal)

Date of Birth (Fecha de Nacimiento) / / Social Security (Seguro Social)

Male Female Transgender (Sexo: Femenino Masculino Transgénero ) Marital Status (Estado Civil)______________________

Home # (Teléfono) Work # (Trabajo)

Cell # (Celular) Email (Correo electrónico)

I prefer to be contacted by: (¿Como prefiere que nos comuniquemos con usted?)

Telephone (Teléfono) Cell Phone (Celular) Text (Texto) Email (Correo electrónico)

Responsible Party Information (Información de la Persona Responsable):

If same as above, check box (Si es la misma información de la parte superior, marque la casilla):

Legal Last Name (Apellido(s) completos)

Legal First Name (Nombre completo) MI

Preferred Name (Nombre preferido)

Permanent Address (Dirección permanente) Apt #:

City (Ciudad) State (Estado) Zip Code (Código Postal)

Date of Birth (Fecha de Nacimiento) / / Social Security (Seguro Social)

Home # (Teléfono) Work # (Trabajo)

Cell # (Celular) Email (Correo electrónico)

Relationship to Patient (Relación con el paciente)

Emergency Contact (Información del Contacto de Emergencia):

Legal Last Name (Apellido(s) completos)

Legal First Name (Nombre completo) MI

Permanent Address (Dirección permanente) Apt #:

City (Ciudad) State (Estado) Zip Code (Código Postal)

Telephone (Teléfono) Relationship to Patient (Relación con el paciente) ______________

Updated 1.18.2017

Demographic Information (Información demografica):

Race? (¿Raza?) Ethnicity? (¿Etnicidad?)

American Indian/Native Alaskan (Indio Americano/Nativo de Alaska) Hispanic/Latino (Hispano/Latino)

Asian (Asiatico) Not Hispanic/Latino (No Hispano/Latino)

Black/African American (Negro/Africano Americano)

Hispanic/Latino (Hispano/Latino)

Native Hawaiian/ Other Pacific Islander (Hawaiano Nativo/Habitantes de las Islas del

Pacifico)

White (Blanco)

Primary Language (Primera lengua/lengua materna)

Insurance Information (Información de Seguro Dental):

Medicaid? YES or NO (SÍ o NO) Medicaid Number (Numero de Medicaid)

Dental Insurance (Seguro Dental) YES or NO (SÍ o NO) If your answer is no, please do not fill out the rest of this section (Si su respuesta es no por favor no llene el resto de esta sección)

Policy Holder’s Name (Titular de la Poliza)

Employer Name & Phone (Nombre y number de telefono del empleador)

Insurance Company’s Name (Nombre de la compañía de seguros)

Insurance Company Address (Dirección de la compañía de seguros)

Insurance Company Phone (Número de teléfono de la compañía de seguros)

Date of Birth of Insured Party (Fecha de nacimiento del asegurado) / /

Relationship to Patient (Relación con el paciente)

Group/Policy # (Numero de Grupo/Poliza)

Social Security Number (Numero de Seguro Social)

Secondary Dental Insurance (Seguro Dental Secundario) YES or NO (SÍ o NO) If your answer is no, please do not fill out the rest of this section (Si su respuesta es no por favor no llene el resto de esta sección) Policy Holder’s Name (Titular de la Poliza)

Employer Name & Phone (Nombre y number de telefono del empleador)

Insurance Company’s Name (Nombre de la compañía de seguros)

Insurance Company Address (Dirección de la compañía de seguros)

Insurance Company Phone (Número de teléfono de la compañía de seguros)

Date of Birth of Insured Party (Fecha de nacimiento del asegurado) / /

Relationship to Patient (Relación con el paciente)

Group/Policy # (Numero de Grupo/Poliza)

Social Security Number (Numero de Seguro Social)

Medical and Dental History Evaluation

Patient Name___________________________________________________________________

Date of Birth________________________________Height (inches): ___________________________ Weight (lbs):_________________________

Do you have any of the following diseases or problems (active tuberculosis, persistent cough, cough producing blood, exposed to tuberculosis)? YES NO

If yes, specify: ________________________________________

____________________________________________________

GENERAL MEDICAL INFORMATION: Are you now, or have you been in the past year, under the care

of a physician? YES NO If so, please provide the name, location and phone number of your physician.

____________________________________________________

____________________________________________________

Have you had any serious illness, operation, or been hospitalized in the past 5 years? YES NO If yes, specify: ________________________________________

Have you had an organ transplant? YES NO If yes, specify: ________________________________________

Have you had open heart surgery? YES NO If yes, specify: ________________________________________

Have you had an orthopedic total joint _ (e.g. hip, knee, elbow, finger) replacement? YES NO

If yes, specify: ________________________________________

Have you ever had any radiation therapy or chemotherapy for a growth, tumor or other condition? YES NO

If yes, specify: ________________________________________

Have you taken (within past 2 years) or are you now taking steroids (e.g. Cortisone)? YES NO

If yes, specify: ________________________________________

Have you taken, are you taking or are you scheduled to begin taking oral bisphosphonates (Alendronate (Fosamax, Fosamax Plus D), Etidronate (Didronel), Ibandronate (Boniva), Risedronate (Actonel), or Tiludronate (Skelid))? YES NO

Have you taken, are you taking or are you scheduled to begin taking intravenous bisphosphonates (Clodronate (Bonefos), Pamidronate (Aredia) or Zoledronic Acid (Reclast, Zometa))? YES NO

TOBACCO USE: Do you use or have you used tobacco

(smoking, snuff, chew, bidis)? YES NO If yes, specify_________________________________________

ALCOHOL USE: Do you drink alcoholic beverages? YES NO

FALL RISK ASSESSMENT: Have you fallen or almost fell in the past

three months? YES NO Do you have a fear of falling? YES NO Do you have difficulty walking or moving around? YES NO Do you use an assistive device such as a cane, walker,

wheelchair, crutches or artificial limb? YES NO If yes to any of the above, please specify: _____________________________________________________

_____________________________________________________

DRUG USE: Do you use prescription or street drugs or other

substances for recreational purposes? YES NO If yes, specify: ________________________________________

FEMALES ONLY: Are you pregnant? YES NO Are you nursing? YES NO Are you taking birth control pills,

fertility drugs, hormonal replacement? YES NO If yes, specify: _________________________________________

ALLERGIES: Do you have any allergies (medications, food, other?) YES NO If yes, specify: ________________________________________

MEDICAL CONDITIONS: Do you have or have you had any of the following diseases,

problems, or symptoms? • Heart/Blood Pressure problem YES NO • Respiratory/Lung problem

(including sleep apnea) YES NO • Diabetes/Endocrine disorder YES NO • Kidney/Urinary disorder YES NO • Cancer or Tumors YES NO • Neurologic/Nerve problem YES NO • Psychiatric disease/Mental Health Disorder YES NO • Blood/Hematologic disorder YES NO • Stomach/Intestine/Liver disorder YES NO • Muscle/Bone/Connective Tissue disorder YES NO • Infectious disease YES NO • Head/Eye/Ear/Nose/Throat problem YES NO • Dermatologic/Skin problem YES NO • Eating disorder YES NO

Do you have any other problem, disease or condition not listed above? YES NO If yes, specify: _________________________________________

Medical History

DENTAL PROBLEMS (SIGNS/SYMPTOMS): Are you currently experiencing dental pain or discomfort? YES NO

If “Yes” to the previous question please mark on the pain schedule how much pain you have.

Are your teeth sensitive to cold, hot, sweets or pressure? YES NO If yes, specify: ________________________________________

Do you have problems with eating (trouble chewing, trouble swallowing, vomiting, etc)? YES NO If yes, specify: ________________________________________

Do you have swelling in or around your mouth, face or neck? YES NO If yes, specify: ________________________________________

Do you have loose teeth? YES NO If yes, specify: ________________________________________

Do you have headaches, earaches or neck pains? YES NO If yes, specify: ________________________________________

Do you have any clicking, popping or discomfort or limited opening in the jaw? YES NO If yes, specify: ________________________________________

Do you have sores or ulcers in your mouth? YES NO

If yes, specify: ________________________________________

Have you ever had a serious injury to your head or mouth? YES NO

If yes, specify: ________________________________________

Are you unhappy with your smile or the appearance of your teeth? YES NO

PAST DENTAL TREATMENT: Have you been to the dentist before? YES NO If so, what is the name, location and phone number of your

dentist? ____________________________________________ ___________________________________________________

Do you have a history of significant dental therapy (implants, cosmetic procedures or TMJ surgery)? YES NO If yes, specify: ________________________________________

Have you had any periodontal (gum) treatments? YES NO

If yes, specify: ________________________________________

Do you have bridges or wear dentures or partials? YES NO If yes, specify: ________________________________________

Have you ever had root canal treatment? YES NO If yes, specify: ________________________________________

Have you ever had orthodontic (braces) treatment? YES NO

Have you had a local anesthetic (Novocaine) for dental purposes? YES NO

Have you had any problems associated with previous dental treatment? YES NO

If yes, specify: ________________________________________

DENTAL DISEASE PREVENTION (ORAL HYGIENE/DIET): How often do you brush your teeth? ______________________ How often do you floss your teeth?________________________ Do your gums bleed when you brush or floss? YES NO

ORAL HABITS: Do you clench, brux, or grind your teeth? YES NO If yes, specify: ________________________________________

MEDICATIONS: Are you taking, have you recently (within the last month) taken,

or are you supposed to be taking any medications (prescription, over the counter, diet supplements, vitamins, natural or herbal)? YES NO

If yes, please list all medications: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dental History

What is the reason for your dental visit today? ___________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

0

None Mild Moderate Severe

1 2 3 4 5 6 7 8 9 10

0 2 4 6 8 10No hurt Hurts

a Little BitHurts a

Little MoreHurts

Even MoreHurts a

Whole LotHurtsWorst

PAIN RATING SCALE

EV 1.11.18

Notice of Billing Practices

Payment

Medical and Dental Services provided by the University of Colorado School of Dental Medicine are payable in full

at the time of service. Please be prepared to pay when you arrive. Outstanding balances must be paid before

further treatment can be scheduled. We accept the following:

Cash, Most Major Credit Cards, Personal Checks, Money Orders, and Debit Cards

Copayments and amount due for non-covered services (including deductible) will be expected at time of

service

Medical and Dental Insurance

Please bring your medical and dental insurance information with you to the consultation visit so we can expedite

reimbursement. We will work hand in hand to maximize your insurance reimbursement for covered procedures.

Please know your dental and medical insurance benefits. The surgeons will make a decision based on the

consultation whether the treatment will be billed to your medical or dental insurance. If you do not have medical

insurance and the oral and maxillofacial surgeons deem the treatment is medical, you will be required to pay out-

of-pocket. If you do not have dental insurance and the oral and maxillofacial surgeons deem the treatment is

dental, you will be required to pay out-of-pocket.

Private Insurance

Insurance is billed as a courtesy to the patient. We recommend requesting a pre-determination for treatment

above $200. All disputes of insurance coverage are between the patient and their insurer. The school does not

intervene in disputes between patients and their insurers. The dental and medical benefit plan is based upon a

contract made between your employer and the insurance company. Should questions arise regarding your dental

and/or medical benefits, it is best for you to contact your employer or insurance company directly. We will do our

best to interpret your benefit plan, but we cannot guarantee actual reimbursement coverage from it. Please

remember you are fully responsible for all fees charged by our office regardless of your insurance coverage. Any

remaining balance after your insurance has paid its portion is your responsibility.

Medicaid/Medicare/Tricare

We are currently accepting both Medicare, Medicaid and Tricare. If you have either insurance and there is a co-

payment required, it will be collected when services are rendered. Please understand that we are required to

collect at time of service. Applicable waivers will be provided for signatures at appointment. Medicaid patients

need to present their Medicaid identification card at each visit in order to meet Colorado eligibility verification

requirement. This must be done prior to the appointment.

I have read the above payment options and insurance information and understand my financial responsibility to

this organization

Patient of Guardian Signature Date Signed

(Building entrances)

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E. 17th Place

E. Montview Blvd.

E. 19th Place

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E. 22nd Ave.E. 23rd Ave.

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PATIENTDROPOFF/PICKUP AT

ROUNDABOUT

13065 E. 17th Avenue • Aurora, CO 80045 • 303-724-6900 www.ucdenver.edu/dentalmedicine

Parking and Patient Dropoff/Pickup at CU Dental Clinics

• From Colfax, head north on Aurora Court

• Turn right at 17th Avenue

• Drive past the School of Dental Medicine – vehicles allowed on pedestrian pathway

• Turn left into the Kiowa lot

The Kiowa lot allows for 1-4 hours parking for our patients. ($1/hour rate)

Additional parking is available in the follow lots:

• Julesburg • Georgetown • Ignacio • Henderson Garage

Handicapped parking meters are available west of the building. ($0.25/15 minutes)

E 470C 470

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E 470

E 470NW Pkwy

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