This information is vital to allow us to provide appropriate care for you. Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important inter-relationship with the dentistry you will receive. Thank you for answering the following thoroughly and honestly.

Confidential Patient Information

Full Name
Prefix (please check) /Sex
Billing/Mailing Address
City / State / Zip
Physical Address
City / State / Zip
Home Phone
Cell Phone
Social Security Number
E-mail Address
Marital Status
Employer / Student
Preferred Contact Phone #
Which is:
Emergency Contact – Name

For Children

Father’s Name
Mother’s Name

Confidential Patient Information Continued

Have you or a family member been a patient in this office before?
Name of Family Member
Whom may we thank for referring you to our office?
General Dentist
Medical Doctor
Pharmacy Name
Location / Phone

Financially Responsible Party

Please check one
Prefix (please check) /Sex
Marital Status
City / State / Zip
Home Phone
Cell Phone
Social Security Number


I understand that unless other arrangements have been made prior, all fees are due in full the day the service is rendered. I authorize Weston Center for Oral and Maxillofacial Surgery to disclose pertinent medical/dental information to my insurance company when indicated to facilitate a claim.
I authotorized

Confidential Health Questionnaire

Prescribed current medications?
Please List
Are you allergic to any medications?
Please List
Do you pre-med?
If yes, what condition?
What Antibiotic?

Do you have or have you ever had (Please check)

Angina or Chest Pain
Ankle Swelling
Artificial Heart Valve
Atrial Fibrillation
Congenital Heart Disease
Heart Failure
Heart Murmur
Heart Valve Problems
Irregular Heart Beat
Abnormal Bleeding
Heart Stent
If yes, when?
Heart Attack
If yes, when?
Heart Surgery
If yes, when?
If yes, when
If yes, when?
Vascular Disease
Alcohol Abuse
Drug Abuse
Artificial Joints
Chronic Pain
Autoimmune Disease
If yes, please list
Hearing Impaired
High Blood Pressure
Liver Disease
Kidney Disease
If yes. please list
Chest Pains
Malignancy / Cancer
If yes, please list
Neurologic Disease
If yes, please list
Shortness of Breath
Sleep Apnea
Sinus Problems
Thyroid Disease
Have you ever had any serious illness not listed above or anything else we need to know?

Confidential Health Questionnaire Continued

Do you use tobacco products in any form?
Do you smoke tobacco?
If so, packs per day
Do you use marijuana?
Do you use any alcohol products?
If yes, drinks per week
Have you been hospitalized in the past year?
Have you ever had radiation therapy to the head or neck?
Have you ever taken bisphosphonate drugs (drugs that strengthen your bones)?
Have you ever taken medications that affect your bone?
If yes, please list
Have you ever taken cancer medications for bone disease?
If yes, please list
Do you get infusions?
Past Surgeries

Female Patients Only

Are you pregnant or nursing?
(If unsure, please check with your physician prior to any surgical procedure.)
Do you use oral contraceptives?
Certain antibiotics prescribed in this office may interfere with the effectiveness of oral contraceptives. It is recommended that you use an additional method of birth control if antibiotics are prescribed. However, continue the use of your birth control as prescribed.


I have read, understood, and attest that the medical history I have given is full and correct.
Patient Name
Patient Signature

Personal Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my stand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient Name
Relationship to Patient
I do hereby authorize and give my consent to Weston Center for Oral and Maxillofacial Surgery to discuss or release my medical records, X-rays and any other information regarding my treatment and appointments to:

Dental Insurance Information

If you have dental insurance we will be happy to send a claim to your dental insurance provider on your behalf. In order to do so, we will need all the below information filled out. We will also need a copy (front and back) of your dental insurance card. If your dental insurance is under your Medical Insurance, you will need to call them to get the Dental Claims address. We are out of network with all Insurance providers (Medical and Dental) but we will send a dental claim if you provide us with all the information needed. Note: We cannot send Dental Claims to your Medical Insurance.
Dental Insurance?
Dental Insurance Company
Dental Claims Address:
Policy # / ID # / Member #:
Group #
Subscriber’s Name / Primary Person
Date of Birth
Social Security Number
Reminder that all payment is due at the time of service, We do not accept insurance as a form of payment

COVID-19 Message to Our Patients

To our wonderful patients, friends, and colleagues,

We hope that you have been safe and healthy, and adapting well to this unique environment. It does not have to be said the extent that this pandemic has challenged our sense of normalcy. Our community has been through a lot over the last few months, and all of us are looking forward to resuming our daily routines. While many things have changed, our commitment to patient safety and infection control has remained paramount.

This practice was founded 60 years ago on a commitment to outstanding patient care with a personal touch. From our office design to treatment protocols, from a warm welcome when you arrive in our open-door policy for our patients, we have developed a reputation for being open and accessible. The greatest challenge in this COVID-19 environment is the need to now balance this concierge experience with patient safety.

Our office follows infection control recommendations made by the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC), and the Occupational Safety and Health Administration (OSHA). We closely follow these agencies and take immediate actions when indicated to ensure our infection control procedures meet and exceed these recommendations.

To keep our patients and staff safe in this unparalleled time, you may notice the following important changes:

- Our office will communicate with you before your appointment with COVID-19 screening questions

- We are reducing the number of patient exposures by streamlining the consult, treatment, and then post-operative experience

- We ask that all patients enter our facility wearing a mask

- Our waiting area will be managed to allow for social distancing which means less available seating and will no longer have periodicals and refreshments

- Hand sanitizers and air purification systems throughout the office

- All staff will be wearing personal protective equipment (but we are still smiling under the masks)

- You and your guests may be asked to remain in your vehicle for portions of your appointment

Lastly, our practice has always strived to provide short wait times to see our doctors. Nothing is more frustrating than sitting for an hour waiting on an appointment. In this continued spirit, we will do our best to schedule you allowing for social distancing. This may mean adjusting your appointment times accordingly. We ask for your patience and support as we do our best to provide the highest level of care safely in this challenging environment.

Dr. Nathan Eberle MD, DDS, FACS

Giving consent to having dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below.
  • Fever

  • Shortness of Breath

  • Dry Cough

  • Runny Nose

  • Sore Throat

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus and the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible in dentistry.

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.

I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.

Relationship to patient

Medicare Opt-Out Private Contract

Physicians and practitioners who do not wish to enroll in the Medicare program may "opt out" of Medicare. This means that neither the physician nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket, and neither party is reimbursed by Medicare. A private contract is signed between the physician and the beneficiary that states, that neither one can receive payment from Medicare for the services that were performed. "Part D Prescriber Enrollment Opt-Out."
This contract between Dr. Nathan Eberle MD, DDS, FACS and

(Medicare beneficiary, referred to in this contract as "Patient") allows Dentist to provide treatment to Patient without being subject to Medicare limits.

To do so, the law requires Dentist to "opt out" of Medicare and that no Medicare claim be filed for the treatment of Patient by Dentist.

Dentist represents that Dentist is excluded from participation under the Medicare program under §1128, 1156, 1892 of the Social Security Act;

In addition, Patient and Dentist agree that Patient is not now facing an emergency or urgent health care situation.

By signing this contract, Patient does the following:

(i) agrees not to submit a Medicare claim (or to request that Dentist submit a claim) for services or items supplied by Dentist, even if they are otherwise covered under Medicare;

(ii) agrees to be responsible, whether through insurance or otherwise, for payment of services or items supplied by Dentist, and understands that no reimbursement will be provided under Medicare for those services or items; [add if applicable: in particular, Patient will pay for such services at Dentist's usual rate, in accordance with Dentist's payment policies;]

(iii) acknowledges that Medicare limits do not apply to amounts that Dentist may charge for such services or items;

(iv) acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to, make payments for items and services covered by this contract, because payment is not made under Medicare; and

(v) acknowledges that Patient has the right to have such services or items provided by other dentists or practitioners for whom payment would be made under Medicare. (Patient is not required to enter into private contracts that apply to other Medicare covered services furnished by other dentists who have not opted out.)
Accepted and Agreed: Dr. Nathan Eberle MD, DDS, FACS Oral Surgeon
Accepted and Agreed:
Patient or Patient's Legal Representative
9:00am - 4:00pm 9:00am - 4:00pm 9:00am - 4:00pm 9:00am - 4:00pm Emergency Hours Available Emergency Hours Available Emergency Hours Available Dr. Nathan Eberle MD, DDS, FACS,3,,,