Dr. Robert E. Pierce, DMD, PA

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Transcription:

Information for patients having surgery with: Dr. Robert E. Pierce, DMD, PA 1) Verify your personal Medicaid Coverage with your social worker. QMB does not cover dental procedures. 2) Make an APPOINTMENT with your MEDICAL DOCTOR for Outpatient Surgery/Anesthesia Clearance. Take all your medications to this appointment along with the following paperwork: a) History and Physical Form b) Patient Questionnaire/Nursing Assessment c) Information Sheet for Scheduling your Surgery 3) Once your physical exam has been completed, before you leave the office, have the Doctor s Office fax the above forms to the Surgical Center for Excellence. The FAX number is 850.522.1940. 4) Keep all the original paperwork and BRING IT WITH YOU ON THE DAY OF SURGERY. 5) ONCE YOUR PAPERWORK HAS BEEN FAXED, the surgery center will call you to schedule a surgery date with Dr. Pierce. Surgery cannot be scheduled UNTIL we have all your paperwork. 6) On the day of your surgery bring: a) Any Dental X-Rays b) Your Medicaid Card c) A Photo ID (i.e. Driver s License, Military ID, Passport, Student ID, etc) 7) Bring legal documents concerning Power of Attorney, legal guardianship, and custody arrangements. We must have a surgical consent signed on the day of surgery or we CANNOT do the surgery. 202 Doctors Drive Panama City, Fl 32405 Phone: (850)522-7722 Fax: (850)522-6903 E-mail: surgicalcenterpc.com

SURGICAL CENTER FOR EXCELLENCE MASTER MEDICATION LIST ALLERGIES: Name of food or Drug **Please list all prescription medications and all over-the-counter medications/supplements/vitamins that you are currently taking.** Date Medication Mg Dosage Medication history recorded/verified with patient by: Date: Patient signature( acknowledgment of receipt of copy of master Medication List): Date: Robert E. Pierce, DMD Date PATIENT LABEL

Robert E. Pierce, DMD HISTORY AND PHYSICAL, Outpatient Surgery/Anesth Clearance (SCE 850.522.1930) Patient s Name: Chief Complaint: History of Present Illness : Allergies: Current Medications: (Refer to Patient Master Medication List) Past Medical History: REVIEW OF SYSTEM: CARDIAC: RESP: Tobacco HX: Alcohol: NEURO: GU: GI: PHYSICAL EXAMINATION: BP Weight Height General: HEENT: Neck: Breasts: Heart: Lungs: Abdomen: GU-Rectal: Extremities/Neuro: IMPRESSION: PLAN: R. Pierce, DMD Signature of Physician Date 850.502.0011 PRINT NAME OF PHYSICIAN

Information needed to schedule your surgery with Dr. Robert E. Pierce, DMD, PA Patient Name: Parent or Legal Guardian Name: Relationship to Patient: Patient Date of Birth: GENDER: M / F Ethnicity: African-Amer Asian Caucasian Hispanic Native Amer Other Patient Address: Patient s MEDICAID NUMBER: Patient s SOCIAL SECURITY NUMBER: Best Phone Number for Contact: Home Phone Number: Cell Phone Number: Other Insurance: 202 Doctors Drive Panama City, Fl 32405 Phone: (850)522-7722 Fax: (850)522-6903 E-mail: surgicalcenterpc.com

Robert E. Pierce, DMD, FAGD Destin/Panama City, FL 850.502.0011 c Informed Consent for Extractions/Oral Surgery I understand it is recommended that I have the following extractions/surgery: Alternatives have been explained to me, but, are Declined I understand that if I choose to do nothing, I may experience pain, infection, and swelling that may compromise adjacent teeth, tissue and facial structures I understand that complications can occur which may require I see another doctor/dentist and I may incur additional expenses I understand the following risks and complications that may occur: Infection Dry Socket Bleeding Bruising Swelling Damage to adjacent teeth, restorations or structures Sinus Involvement with upper jaw teeth Root tip breakage and displacement Fracture of jaw or supporting structures Nerve damage which may cause a loss of feeling in lips, teeth, tongue, and Surrounding areas for an indefinite amount of time, even permanent I understand complications may arise during surgery that require immediate changes to the agreed upon treatment, but, will only be exercised as needed by my clinical judgement and experience. I agree I have been given the time and attention to answer all of my questions. Patient Date Witness Date

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