The Dermatology Center at Ladera

Phone: 972-985-1920  Fax: 972-985-1176  Web: www.selkinoralsurgery.com

REMINDERS OF REQUIRED ITEMS

FOR YOUR VISIT

• Insurance Cards If you have health insurance, we

cannot see you without making a copy of your

insurance card.

• Written Referral from your Primary Care Physician

if required by your insurance plan.

• Co-pay or Deductible is collected at the time of visit

• Cosmetic procedure fees are due at time of visit

• Completed Patient Registration Package

• Driver’s License or State Issued Photo ID

Gilbert T.Selkin MD, DMD

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

We are pleased to welcome you to our practice!

Attached is our Patient Registration Package. Please complete these forms to help us maintain

accurate contact and medical records. If you printed these forms from our website, you may fax

them to us at 972-985-1176 prior to your appointment, or bring the completed original forms with

you to your appointment along with the other items requested below.

We realize that you have a choice of where to be treated. We also understand and respect the great

deal of trust in your physician. We want to provide you with the most up to date information and

treatment options regarding your oral and skin care health. We do appreciate and value the trust you

have placed in us.

We provide our patients and their families with full-service, comprehensive oral and maxillofacial

surgery. We desire to assist you in receiving the best of what today’s medicine has to offer. We are

highly committed to quality patient care with an emphasis on individual attention for each patient.

Providing the best service, in a comfortable, private atmosphere is extremely important to us. We

assure you, we will do our best to give you total satisfaction.

We value highly the relationship with our patients. We especially value patient feedback.

Therefore, we will ask you to communicate to us your experiences at our practice. Your feedback

matters because it helps us continue to serve you and our other patients with the highest level of care

possible. If you have any questions or concerns, please do not hesitate to ask any member of our

team.

Warmest Regards,

Gilbert T. Selkin MD, DMD.

Gilbert T. Selkin MD., DMD.

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

PATIENT INFORMATION

Last Name: _________________________________________________

First Name: _________________________________ MI: __________

Previous Name: ______________________________________________

(Maiden name, former married name, etc.)

Home

Address: __________________________________________

(No PO boxes)

City: __________________________________________

State: ___________ Zip Code: ______________________

Number for appointment reminders and test results: (_____)___________

May we leave a message at this number?  Yes  No

Secondary Phone: (____)_________Work Phone: (______)____________

Preferred Language:  English  Spanish  French  Italian

Dentist: ___________________________________________________

(First and Last Name)

Phone: __________________________

If YES, name of referring provider: _______________________________

Race:

 Native American  African American  Asian  White

 Hispanic  Pacific Islander  Other  Unreported/Refused

Ethnicity:

Hispanic/Latino Not Hispanic/Latino Unreported/Refused

Date of Birth: _____________________________

 Male  Female

Marital Status:

 Single  Married  Divorced  Widowed

 Legally Separated  Partner

Social Security Number: _______________________________________

Email: _____________________________________________________

Responsible Party, if different from patient information above:

(statements will be addressed to the responsible party)

Name: _________________________________________________

Address: __________________________________________

City: __________________________________________

State: ___________ Zip Code: ______________________

Date of Birth: _____________________________

 Male  Female

Phone: (______)___________ Email: ____________________________

Relationship to patient: __________________________________

Adult Emergency Contact:

Name: _________________________________________________

Address: __________________________________________

City: __________________________________________

State: ___________ Zip Code: ______________________

Phone: (_______)____________ Alt. Phone: (_______)____________

Relationship to patient: __________________________________

INSURANCE INFORMATION: If the patient is not the primary policy holder, the Responsible Party section above must be completed.



Self Pay

(no insurance)



Patient IS the policy holder



Patient IS NOT the policy holder

Primary Insurance Co.: ____________________________________________ Policy Number _________________________

Secondary Insurance Co.: __________________________________________ Policy Number _________________________

Does your insurance plan require you to have a referral to see a specialist?  No  Yes  I don’t know

NOTE: It is the patient’s responsibility to get any required referrals. Failure to do so may result in denied claims and the patient will be responsible for all services rendered.

SUBSCRIBER INFORMATION (REQUIRED if patient is not the primary

insurance policy holder):

Name: __________________________________________

Social Security #:_______________ Date of Birth:________________

PHARMACY INFORMATION:

Name: _____________________________________________________

Location (City and Intersection):_________________________________

___________________________________________________________

Phone: (_______)_________________

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care

Patient or Responsible Party Signature __________________________________________________________ Date _______________________

How did you find us?

 Family/Friend - Name: _______________________

 Insurance Provider List

 Internet Search

 Newspaper Ad

 Ph ys icia n - Name: ____________________________

 Yellow Pages

 O t h e r ______________________________________

Oral Surgery Health Questionnaire

Gilbert T. Selkin, DMD., MD

Oral and Maxillofacial Surgery

Patient Name: _________________________________ Birth Date: ______________ Chart Number: ____________

Age: ________________ Sex: ________________ Height: _______________ Weight: _______________

PLEASE ANSWER ALL QUESTIONS AND FILL IN BLANK SPACES WHERE INDICATED. ANSWERS TO THE

FOLLOWING QUESTIONS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

1.) Are you in good health? -------------------------------- Yes No

2.) Your last physical examination was on _________

3.) Are you under the care of a physician?-------------- Yes No

If so, what is the condition that is being treated?

_________________________________________

4.) Name and telephone number of the physician

_________________________________________

5.) Have you had any serious illness, operation, or

been hospitalized? --------------------------------------- Yes No

If yes, what was the problem and when?

_________________________________________

6.) Do you drink alcoholic beverages? -------------------- Yes No

If yes, how many per week? __________________

7.) Do you smoke or use tobacco products? ------------ Yes No

If yes, how many cigarettes per day? ___________

8.) Do you take vitamins and/or supplements? -------- Yes No

9.) Do you use any recreational drugs?------------------- Yes No

If yes, what kind? __________________________

How many times per month? ________________

10.) Have you had abnormal bleeding associated with

previous extractions, surgery, or trauma? ----------- Yes No

11.) Do you bruise easily? -------------------------------------- Yes No

12.) Have you ever required a blood transfusion? ------- Yes No

If yes, explain circumstances __________________

__________________________________________

13.) Do you have any bleeding disorder such as anemia? Yes No

14.) Are you taking any drug or medicine? ---------------- Yes No

If yes, what medication? _____________________

_________________________________________

15.) Are you taking any of the following?

A.) Antibiotics or sulfa drugs -------------------------- Yes No

B.) Anticoagulants (blood thinner) ------------------ Yes No

C.) Medicine for high blood pressure -------------- Yes No

D.) Medicine for anxiety or depression ------------ Yes No

E.) Cortizone (steroids) -------------------------------- Yes No

F.) Tranquilizers ----------------------------------------- Yes No

G.) Aspirin ------------------------------------------------- Yes No

H.) Insulin, Tolbutamid --------------------------------- Yes No

I.) Digitalis or drugs for heart problems ---------- Yes No

J.) Nitroglycerin ----------------------------------------- Yes No

16.) Are you taking or have you ever taken:

A.) Bisphosphonates (Fosamax, Actonel, Aredia,

Boniva, Didronel, Skelid, Bonefos, or Zometa)

for osteoprosis, or chemotherapy for multiple

myeloma, etc? --------------------------------------------- Yes No

B.)Fen-Phen (now or in the past) or related drug

such as lonimin, Adipex, Phentramine, Fastin,

Pondimin (fenfluramine), and Redux

(dexfenfluramine) ----------------------------------------- Yes No

17.) Do you grind your teeth at night? --------------------- Yes No

18.) Do you have a history of jaw pain when opening

and closing? ------------------------------------------------ Yes No

19.) Does your jaw pop or click when opening? --------- Yes No

20.) Has your jaw ever been stuck open or closed? ----- Yes No

21.) Have you had surgery or x-ray treatment

for a tumor, growth or other condition in your

mouth or on your lips? ----------------------------------- Yes No

22.) Are you pregnant? ---------------------------------------- Yes No

23.) Are you allergic or have you reacted adversely to:

A.) Iodine -------------------------------------------------- Yes No

B.) Local Anesthetic ------------------------------------- Yes No

C.) Penicillin or other antibiotics --------------------- Yes No

D.) Sulfa drugs -------------------------------------------- Yes No

E.) Barbiturates, sedatives, sleeping pills ---------- Yes No

F.) Aspirin ------------------------------------------------- Yes No

G.) Soybean or egg -------------------------------------- Yes No

H.) Latex --------------------------------------------------- Yes No

I.) Other ________________________________

24.) Have you had any adverse reaction associated

with previous dental treatment? --------------------- Yes No

If yes, please explain ________________________

_________________________________________

25.) Have you had any adverse reaction associated

with previous medical treatment or surgery? ----- Yes No

26.) Have you had any adverse reaction or family

history of adverse reaction to anesthesia? --------- Yes No

27.) Have you ever received any radiation treatment

to the jaws or any area of the head and neck for

any reason? ----------------------------------------------- Yes No

If yes, What location?_______________________

When was treatment? ______________________

Doctor who performed treatment? ____________

28.) Have you had any of the following illnesses? ------ Yes No

AIDS ---------------------------------------------------------- Yes No

Allergies ----------------------------------------------------- Yes No

Anemia ------------------------------------------------------ Yes No

Angina ------------------------------------------------------- Yes No

Anxiety ------------------------------------------------------ Yes No

Anaphylaxis ------------------------------------------------ Yes No

Arthritis ----------------------------------------------------- Yes No

Artificial Joint Replacement ---------------------------- Yes No

Asthma ------------------------------------------------------ Yes No

Bipolar Disorder ------------------------------------------ - Yes No

Blood Clot ________________________________ Yes No

Cancer ------------------------------------------------------- Yes No

Clotting Disorder __________________________ Yes No

Diabetes ----------------------------------------------------- Yes No

Depression ------------------------------------------------- Yes No

Emphysema ------------------------------------------------ Yes No

Epilepsy ----------------------------------------------------- Yes No

Fainting ------------------------------------------------------ Yes No

Glaucoma --------------------------------------------------- Yes No

Heart Attack ------------------------------------------------ Yes No

Hepatitis ---------------------------------------------------- Yes No

High Blood Pressure -------------------------------------- Yes No

HIV Positive --------------------------------------------- --- Yes No

Kidney Disease --------------------------------------------- Yes No

Liver Problem ---------------------------------------------- Yes No

Low Blood Pressure -------------------------------------- Yes No

Lung Disease ----------------------------------------------- Yes No

Mental Illness ---------------------------------------------- Yes No

Rheumatic Fever ------------------------------------------ Yes No

Stroke -------------------------------------------------------- Yes No

Thyroid ------------------------------------------------------ Yes No

Tuberculosis ----------------------------------------------- Yes No

Venereal Disease ----------------------------------------- Yes No

Other: __________________________________

I have filled out this health questionnaire completely. I have advised you of all medical problems of which I am aware.

I have reviewed the health history form above

Patient Signature: _____________________________Date: ____________

Doctor Signature: _____________________________ Date: ____________

Gilbert T. Selkin MD, DMD

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

Patients, or legal guardians of patients under the age of eighteen, MUST sign and date all paragraphs below before

medical care can be rendered.

Release of Medical Information

I authorize the release of medical information to my primary care or referring physician, to consultants if needed, and as

necessary to process insurance claims, insurance applications, and prescriptions.

Signature: _____________________________________________________Date:______/______/______

Financial Policy

Payment is required for all services at the time they are rendered unless the patient is in an insurance plan with which we

participate. For those patients, applicable co-payments, deductibles, and co-insurance will be collected for services rendered.

Once our office has received payment from your insurance, if for some reason insurance decides to pay your charges at a higher

benefit level than what was quoted to our office at the time of service; we will then issue the patient a refund for the over

payment amount or apply a credit on the account. In an effort to ensure the most accurate refund amount please be advised

that our office cannot issue any refunds until all line items have been finalized by your insurance.

We accept payment in the form of cash, check, Visa and MasterCard. In the event that your account must be turned over to

collections, a $25.00 collection fee will be added to your account. For consultations which are missed or cancelled with less

than 24 hour notification, there may be a $25.00 missed appointment fee added to your account. For surgery cancelled with less

than 24 hours notification, there will be a $100 missed appointment fee. Your signature below signifies your understanding and

willingness to comply with this policy.

I have read and understand the financial policy statement. I agree to make in-full prompt payment to Dr. Gilbert T. Selkin, MD

when billed for any and all charges not covered or paid by valid insurance benefits for and in consideration of services rendered.

Further, I authorize payment directly to Dr. Gilbert T. Selkin for medical insurance benefits payable to me under the terms of

my policy but not to exceed the balance due for services performed for my treatments.

I authorize release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose

of evaluating and administering claims for insurance benefits. I hereby authorize payment of insurance benefits directly to the

doctor, or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental

benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all

accounts.

In addition to the above, if I am a Medicare patient, I authorize any holder of medical or other information about me to release

to the Social Security Administration and Center for Medicare and Medicaid Services, or its intermediaries or carrier, any

information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original,

and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

Regulations pertaining to Medicare assignment of benefits apply.

Signature: _____________________________________________________Date:______/______/______

Privacy Practices (HIPAA)

By signing below, I acknowledge that I have read and understand Dr. Gilbert T. Selkin Notice of Privacy Practices.

This document is posted on our website and is always made available at the check-in desk.

Signature: _____________________________________________________Date:______/______/______

Gilbert T. Selkin MD, DMD

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

Some facts about Dental & Medical Insurance

Over 50 % of patients seeking dental care have some type of Dental Insurance-

Or dental “Assistance”, as it should be called. Like Medical Insurance, dental insurance is designed to pay

only a portion of the cost of dental treatment.

Your employer has made this coverage available to you, and the type of benefit you receive depends upon

the type of contract that was chosen with the insurance company. Your employer buys a special contract at a

special fee (or premium) and includes as many or as few benefits as the employer is willing to pay for.

Keep in mind that your oral surgeons fees or services are in no way reflective of what your insurance

deems to be “Usual and Customary” by your insurance company, because remember….your employer

selected your plan for you, not your oral surgeon.

Benefits vary from policy and the premiums that are paid are usually reflective of your individual plan.

(I.e. Higher premium= Higher usual and customary rates and fewer exclusions and limitations)

Unfortunately it would be impossible for Dr. Gilbert. T. Selkin to determine each and every patient’s

policy provisions and limitations. While we are happy to assist you in filing your claims, please keep in

mind that is offered as a courtesy. We will file your insurance for you but if they do not pay within 60

days, it is your responsibility to pay our office and follow up with your dental and medical insurance.

Occasionally there are services that are selected that are “Non- covered” services which vary from plan to plan

and policy to policy.

Some services may include but are not limited to the following:

X- Rays

- Panorex

- Periapical

Dental implants & wisdom teeth extractions

Extractions

Sedation

Biopsy & excision of oral lesions

Your oral health should NEVER be dictated by what your dental or medical insurance will or will not

cover. Please allow us the opportunity to answer any questions that you may have regarding your

insurance coverage.

Patient or Responsible Party Signature_______________________________Date_______________________

Gilbert T. Selkin MD, DMD

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

Surgery Cancellation Policy Effective 12/01/2010

Patients, or legal guardians of patients under the age of eighteen, MUST sign and date below before

medical care can be rendered.

At the Facial & Skin Surgery Center we strive to provide the best and most complete patient care. In an

attempt to preserve patient care, we have a Surgery Cancellation Policy that allows us to schedule appointments

for all patients. When a surgery is scheduled, that extended period of time has been set aside for you. When it is

missed, that time cannot be used for surgery for another patient, or filled with appointments for patients that

urgently need the care.

We request that you please give our office 24 hour notice in the event that you need to reschedule or

cancel your surgery with the physician or physician assistant. This allows other patients in need of care to be

scheduled in that appointment time. It also makes it possible to reschedule your appointment more efficiently.

Patients failing to provide 24 hours notice that they can not make their surgery as scheduled will have a charge

of $100 added to their account. Please note that this charge is the financial responsibility of you, the patient, and

will not be paid by your insurance company. We thank you for your cooperation in this manner so that each

patient can receive the treatment and medical attention that they need and deserve.

I have read and understand the Medical Appointment Cancellation Policy of the practice and I agree to be bound

by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

I have read, understand, and will comply with the Facial & Skin Surgery’s Surgery Cancellation Policy.

_______________________________________________ _________________________________________

Printed Name of Patient or Responsible Party if a Minor Relationship to Patient (if patient is a minor)

_____________________________________________ _________________________________________

Signature of Patient or Responsible Party if a Minor Date

Gilbert T. Selkin MD, DMD

5026 Tennyson Parkway

Plano, TX 75024

Phone 972-985-1920

Fax 972-985-1176

Authorization to Leave a Voicemail

Please provide number(s) ONLY IF you approve us to leave DETAILED information related to appointments,

billing, test results, diagnosis, and procedures on your voicemail.

Primary (______) __________________ Secondary (______) __________________

Authorization to Send an Email Message

Please provide an email address below ONLY IF you approve us to send DETAILED information regarding

your appointment, billing, test results, diagnosis, and procedures in an email.

Email address: _____________________________________

We also offer you to have access to your account online through our web portal, giving you the option to look at billing

information, appointment times, and to send the providers questions or messages through the internet. Would you like to

be web enabled through our web portal?

 Yes  No

Personal Representative Authorization for Medical Release Form

Under HIPAA requirements, we are not allowed to discuss any of your health information with anyone else

without your consent.

I authorize this facility to speak to the following family members or my personal representative regarding

 All medical information, including but not limited to: appointments, billing, test results, diagnosis, and

procedures.

 Only the following types of information: _________________________________________

The above medical information shall only be released to the following person(s):

1.__________________________Relationship: __________________ Phone number: ___________________

2.__________________________Relationship: __________________ Phone number: ___________________

3._________________________ Relationship: __________________ Phone number: ___________________

Authorization to Send a Text Message

Please provide a number ONLY IF you approve us to leave DETAILED information related to appointments,

billing, test results, diagnosis, and procedures in a text message. (_______)_____________________

By signing below I understand and agree to all stated and filled in above; I also understand my rights are

protected by the Privacy Act (HIPAA) and that I may request a copy of this Act at any time.

Name (PRINTED) ________________________________

Signature________________________________________

Date____________________________________________