MICHIANA

ORAL AND BERNARD J. ASDELL, D.D.S.

MAXILLOFACIAL
SURGERY, LLC
707 N. MICHIGAN STREET
MEMORIAL MEDICAL PLAZA
SUITE 300
SOUTH BEND, IN 46601
PH. (574) 289-0080
info@[Link]

Patient Name _____________________________ DOB _______________________

I understand that fees are due when services are rendered. If other arrangements are necessary,
they need to be made before service is rendered. I understand that, as a courtesy, insurance will
be filed, but the RESPONSIBLE PARTY is financially responsible for all charges. Any amount
failed to be paid by the insurance company is between the RESPONSIBLE PARTY and the
insurance company. Accounts are to be paid in full within 60 days from the date of service, and
may be subject to a "LATE CHARGE" of $5 per month in the event the account is not paid in full
during this period. I understand that in the event of collection activity, the RESPONSIBLE
PARTY will be held liable for all interest charges, collection fees, reasonable attorney's fees, and
court costs. I understand that credit inquiries are done on a routine basis.

The Patient, by the signature below, or if a minor, by the parent or responsible party, authorizes
payment directly to Dr. Asdell of the group insurance benefits otherwise payable to Patient. The
signature also authorizes the release of any dental/medical information necessary to process any
claims and authorizes that this document serve as valid signature on file should it become
necessary in the processing of additional claims.

I authorize Michiana OMFS to speak to the person (s) listed below about any information,
regarding treatment, insurance and charges incurred in this office.

_____________________________________________________________________________
(Relationship to patient)
_____________________________________________________________________________
(Relationship to patient)

PATIENT'S SIGNATURE (Parent or Guardian, if minor)___________________________________ Date ______________________

RESPONSIBLE PARTY (If different than patient)____________________________________ Date ______________________
 PATIENT INFORMATION
NAME Name Preferred_______________________ Sex: M  F 
First Middle Init Last
Home Phone ( ) _________________ Work Phone ( ) __________________ ext _____ Social Security#_______________________
Cell Phone ( ) ____________________ Email Address ___________________________________________________________________
Address_______________________________________________ City_____________________________ State_________ Zip____________
Birth date_______________________________ Age____________ Marital Status: Single Married Divorced Separated Widowed
Employer________________________________ Occupation_____________________ # Years Employed________ Full-Time Part-Time
Employer's Address______________________________________ City_____________________________ State_________ Zip___________
Who is your Dentist? ______________ Orthodontist? ________________ Physician? ______________________Phone # _______________
Who may we thank for referring you to our office?
Have you or any other family member ever been seen in this office? ___________ If yes, whom & when?
Emergency contact person, OUTSIDE OF IMMEDIATE HOUSEHOLD? ______________________________ Phone ( )
If patient is a student, please complete:
Name of School______________________________________ City__________________________ State________ Full-Time Part-Time 
RESPONSIBLE PARTY INFORMATION
NAME________________________________________________________________________________________________ Sex: M  F
First Middle Init Last
Home Phone ( ) _____________________________________ Work Phone ( ) ___________________________________ ext ________
Cell Phone ( ) _____________________________________ Email Address ________________________________________________
Address_______________________________________________ City_____________________________ State__________ Zip
How long at this address? _________________________________ Marital Status: Single Married Divorced Separated Widowed
Previous address (if less than 3 years) _____________________________________ City__________________ State__________ Zip
Birthdate__________________ Social Security #______________________ Relationship to Patient
Employer_________________________________ Occupation________________ # Years Employed__________ Full-Time Part-Time
Employer's Address________________________________________________ City___________________ State__________ Zip
SPOUSE______________________________________________ Work Phone ( ) ___________________________________ ext
Birthdate__________________ Social Security #______________________ Relationship to Patient
Employer_________________________________ Occupation________________ # Years Employed__________ Full-Time Part-Time
Employer's Address________________________________________________ City___________________ State__________ Zip

INSURANCE INFORMATION
PRIMARY Insurance Company Name________________________________________________ Phone ( )
Insurance Company Address________________________________________ City____________________ State_________ Zip
ID #_________________________________________ Group #_____________________________________ Medical Dental Both
Policy Holder's Name_________________________________ Birthdate_________________ Relationship to Patient
Address________________________________________________________ City_____________________ State_________ Zip
Is insurance through employer? ____________ If yes, list employer
SECONDARY Insurance Company Name____________________________________________ Phone ( )
Insurance Company Address________________________________________ City____________________ State_________ Zip
ID #_________________________________________ Group #_____________________________________ Medical Dental Both
Policy Holder's Name_________________________________ Birth date_________________ Relationship to Patient
Address________________________________________________________ City_____________________ State_________ Zip
Is insurance through employer? ____________ If yes, list employer
 PATIENT'S MEDICAL HISTORY
Height _________ Weight ___________ BMI____________________
(STAFF USE ONLY)
Yes No
____ ____ Are you allergic to any foods or medications, adhesives or latex products? _______________________________________
____ ____ Are you taking ANY MEDICATIONS? List______________________________________________________________
___________________________________________________________________________________________________
____ ____ Are you taking any herbal supplements? List_______________________________________________________________
____ ____ Are you taking, or have you ever taken bone-enhancing drugs, ie Fosomax, Actonel, Reclast, etc? List ________________
____ ____ Are you now under the care of a physician? What condition is being treated?
____ ____ Are you taking aspirin or blood thinning agents? How often?
____ ____ Have you had any serious illnesses or operations within the last 5 years? Describe
____ ____ Do you smoke? How much?
____ ____ Have you ever had a problem with drug/substance abuse (includes alcohol)? Describe
____ ____ Are you pregnant? Estimated delivery date?
____ ____ Are you breastfeeding? Taking Birth Control Pills? ______Yes ______No
____ ____ Do you have any disease, condition or problem not listed that you think we should know about?
Describe
PLEASE INDICATE IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING CONDITIONS.
Yes No Yes No
____ ____ Anemia ____ ____ Hyperactive
____ ____ Asthma ____ ____ Hypoglycemia
____ ____ Bleeding problems of any kind ____ ____ Joint Replacement
____ ____ Cancer ____ ____ Pneumonia
____ ____ Convulsions/Epilepsy ____ ____ Stomach Ulcers
____ ____ Diabetes ____ ____ Stroke
____ ____ Faint or tire easily ____ ____ Surgery or X-ray for tumor
____ ____ Heart Valve Replacement ____ ____ Tuberculosis (TB)
____ ____ Heart problems of any kind ____ ____ Unusual weight loss
____ ____ Hepatitis ____ ____ Venereal disease
____ ____ High blood pressure ____ _____ TMJ Problems (jaw joint problems)
____ ____ HIV+/AIDS

I understand that the information I have given today is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it
is my responsibility to inform this office of any changes in my medical and residential status.
The Patient, by the signature below, or if a minor, by the parent or responsible party, agrees that permission is granted for treatment by Dr. Asdell.

I understand that fees are due when services are rendered. If other arrangements are necessary, they will need to be made before service is
rendered. I understand as a courtesy, insurance will be filed, but the RESPONSIBLE PARTY is financially responsible for all charges. Any
amount not paid by the insurance company is between the RESPONSIBLE PARTY and the insurance company. Accounts are to be paid in full
within 60 days from the date of service, and may be subject to a “LATE CHARGE” OF $5 per month in the event the account is not paid in full
during this period. I understand that in the event of collection activity, the RESPONSIBLE PARTY will be held liable for all interest charges,
collection fees, and reasonable attorney’s fees, and court costs.

PATIENT'S SIGNATURE (Parent or Guardian, if minor) Date _______________________________

RESPONSIBLE PARTY (If different than patient) Date _______________________________
UPDATED SIGNATURE ___________________________________________________________Date _______________________________