New Patient Packet

Complete each form below, then review and send the full packet to our office.

Riverside Oral Surgery

Confidential Registration

Patient Information
Sex *
Responsible Party Information (if patient is a minor)
Insurance Information
Primary Insurance
Secondary Insurance

Assignment and Release

I understand that I am financially responsible for all charges, whether or not paid by insurance. I, the undersigned, have insurance with:

I assign directly to Shaun Burlingame, DDS, MD, and/or Francisco Suarez, DDS, all benefits, if any, otherwise payable to me for services rendered. I hereby authorize Shaun Burlingame, DDS, MD, and/or Francisco Suarez, DDS, to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

Patient Health History Form

Patient Information
Sex *

An accurate and complete health history will assist in coordinating your dental care. Please speak with the doctor or staff if there are any questions about this form.

Dental History
Please describe your current dental health
Have there been any changes in your dental health in the past year?
Are you having any dental discomfort at this time?
Have you had any adverse effects from dental treatment?
Medical History
Please describe your current overall health
Have there been any changes in your general health in the past year?
Are you now under a doctor’s care for a medical condition?
Have you ever been hospitalized or had a serious illness?
Have you ever had surgery?

Medical History (Continued)

Congenital heart or cardiovascular disease (heart attack, murmur, CAD, chest pain, high/low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)
Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain)
Bleeding disorder, anemia, bleeding tendency, blood transfusion, bruise easily
Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)

Medical History (Continued)

Kidney disease or kidney failure requiring dialysis
Liver disease (jaundice, hepatitis A, B, or C)
Diabetes
Thyroid disease
Arthritis
Sinus or nasal problems
Significant weight loss or gain
Sleep apnea
Radiation to the jaws or head and neck area
Cancer
Osteoporosis or osteopenia
Do you have any other medical conditions that are important for your doctor to know about?

Medications

Are you currently prescribed or taking any of the following?

Antibiotics
Anticoagulants or blood thinners
Heart medications
Steroids (cortisone or prednisone)
Antianxiety agents, antidepressants, or other psychiatric medications
Cancer or chemotherapy drugs
Prescription pain medication
Aspirin or drugs such as Motrin, Aleve, Ibuprofen
Insulin or oral anti-diabetic drugs
Blood pressure medications
Bisphosphonates (Fosamax, Boniva, Actonel, Prolia, Jubbonti, Xgeva, etc.)
GLP-1 medications (Mounjaro, Wegovy, Ozempic, Zepbound, etc.)

Please list the specific medications indicated above and/or any other medications not listed above that you are currently taking. Please include all prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins, or minerals:

Allergies

Are you allergic to or have you had an adverse reaction to:

Latex
Food or food products
Sedatives
Codeine or other pain control medications
Aspirin, ibuprofen (Motrin), or naproxen (Aleve)
Penicillin or other antibiotics
Any other medications
Any other allergies

Please list any allergies or adverse reactions, including the substance and the type of reaction:

Anesthesia History

Have you had any problems associated with local anesthesia, general anesthesia, and/or intravenous sedation?

Female Patients

Are you pregnant?
Is there any chance you might be pregnant?

Social History

Have you ever smoked, vaped, or chewed tobacco?
Do you use alcohol?
Do you use marijuana?
Do you use recreational drugs?
Do you wish to talk to the doctor about anything in private?

Signature & Acknowledgment

I understand the importance of a truthful and complete health history to assist my doctor(s) in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

Riverside Oral Surgery

Effective Date: February 1, 2026

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

The privacy of your health information is important to us.

Riverside Oral Surgery

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and California privacy laws, we are required to maintain the privacy and security of your protected health information (PHI). We are also required to post in a clear and prominent location, and provide patients with this Notice of Privacy Practices, which details our privacy practices, our legal duties, and your rights concerning your PHI. This Notice is currently in effect, and will remain in effect until we replace it.

We reserve the right to change our privacy practices, and the terms of this Notice, at any time, provided such changes are permitted by law. If changes are made, a new Notice of Privacy Practices will be displayed in our office and will be available upon request. You may request a copy of our Notice at any time.

We will let you know promptly if a breach occurs that may have compromised the privacy and security of your PHI. We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time. Let us know in writing.

Uses and Disclosures of Health Information

The following describes how PHI about you may be used in this dental office:

  • Treatment Services: We may use or disclose your PHI to a physician or other health care provider providing treatment to you.
  • Payment: We may use and disclose your PHI to obtain payment for services we provide to you. Upon your written request, we will not disclose to your health insurer any services paid by you out of pocket.
  • Healthcare Operations: We may use and disclose your PHI in connection with our healthcare operations, which include quality assurance, disease management, training, licensing, and certification programs.
  • Other Authorizations: In addition to our use of your PHI for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your PHI for any reason except those described in this notice.
  • Family Members, Friends, and Others Involved in Care: Only if you agree that we may do so, we may disclose your PHI to a family member, friend, or other person if necessary to assist with your treatment and/or payment for services. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. If you are present, then prior to use or disclosure of your PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose PHI that is directly relevant to the person’s involvement in your healthcare. Your PHI may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.
  • Marketing/Fundraising: We will not use your PHI for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your PHI without your explicit authorization.
  • Appointment Reminders: We may use or disclose your PHI to provide you with appointment reminders such as voicemail messages, text messages, email, postcards, or letters. We will use unencrypted email for communicating with you at your specific request only.
  • Legal Requirements: We may disclose your PHI when required to do so by law.
  • Abuse or Neglect: If abuse, neglect, or domestic violence is reasonably suspected, we may use or disclose your PHI to the appropriate authorities to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
  • National Security: When required, we may disclose to military authorities the PHI of Armed Forces personnel. Information may be given to authorized federal officials when required for intelligence, counterintelligence, and national security activities. Under certain circumstances, we may disclose PHI of inmate(s) to correctional institutions or law enforcement officials having lawful custody of the inmate(s).
  • Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your PHI to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All of our business associates are required to safeguard your PHI and to follow HIPAA Privacy Rules.
  • Public Health Activities: We may disclose medical information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products, to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition.
  • Additional Restrictions on Use and Disclosure: Some laws may require special privacy protections that restrict the use and disclosure of certain types of PHI: alcohol and substance use disorders, biometric information, child or adult abuse or neglect including sexual assault, communicable diseases, genetic information, HIV/AIDS, mental health, prescriptions, reproductive health, and sexually transmitted diseases. We will follow the more stringent law, where it applies to us.
  • Substance Use Disorder (SUD) Information: Although we are not a SUD treatment program under federal law, we may receive information from a SUD Program about you. We may not disclose SUD information for use in a civil, criminal, administrative, or legislative proceeding against you unless we have (i) your written consent, or (ii) a court order accompanied by a subpoena or other legal requirement.
  • Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, access, use or disclosure.

Patient Rights

  • Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information.

    We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request x-Rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator.

  • Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
  • Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We will keep your information confidential from your health plans if you pay in cash, at your request. In some instances, we may not be required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
  • Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
  • Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and must explain the reason for the amendment.) We may deny your request under certain circumstances.
  • Electronic Notice: If you receive this Notice on our website or by email, you are entitled to receive this Notice in written form.

Questions and Complaints

If you want more information about our privacy policy or have questions or concerns, please contact us. If you have concerns relating to a perceived violation of your privacy rights, to access to your health information, to amending or restricting the use or disclosure of your health information, or to requesting alternative means of communication, you may contact us using the contact information listed at the end of this Notice. You also may submit a written complaint to the Department of Health and Human Services (HHS). We will provide you with the HHS address upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the HHS.

Privacy Officer: Riverside Oral Surgery
Telephone: 530-223-1811
Fax: 530-223-1813
Email: office@riversideos.com
Address: 316 Knollcrest Drive, Redding, CA 96002
Riverside Oral Surgery

Patient Acknowledgement of Receipt of Notice of Privacy Practices

By signing this form, you are giving this office your consent to use and disclose health information about you for treatment, payment, and health care operation purposes.

I have recognized this practice’s Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information.

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by this practice. I understand I can obtain this practice’s current Notice of Privacy Practices on request.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Shaun Burlingame, D.D.S., M.D. | Francisco Suarez, D.D.S. | Oral & Maxillofacial Surgery | Dental Implants | 316 Knollcrest Drive, Redding, CA 96002 | P 530-223-1811 | F 530-223-1813 | https://www.riversideos.com
Riverside Oral Surgery

Our Financial Policy

It is very important that you read this document carefully!

If you are covered by dental insurance, we will, at the time services are rendered, bill your insurance provider as a courtesy to you. We will collect payment in full for the treatment to be rendered. Any payment received by your dental insurance will be reimbursed to the patient directly or can be kept as a credit on account to be applied for future treatment.

We are not a provider for Medicare, or any other medical insurance. Medicare will not pay for any procedure that is performed by Dr. Burlingame and/or Dr. Suarez and the cost is due in full by you, the patient, at the time services are rendered.

If you are a cash paying patient, payment is due on the day of your treatment surgery. There are no exceptions.

For extensive surgeries, such as full mouth extractions or facial trauma surgery, 50% of the cost of your procedure is due at the time of your consultation if you elect to schedule the procedure with our office. The remaining 50% is due on the day of surgery. There are no exceptions.

We do not offer an in-house payment plan. You may inquire about Care Credit or Sunbit options if you would like to establish a dental/medical line of credit to pay for your visit. This must be arranged prior to your treatment time. Past due accounts are sent immediately to collections.

We ask that you sign below as an acknowledgment that you have read and understand our financial policy. This policy is effective December 1, 2009.

By signing, I acknowledge that I have read the above Financial Policy and agree to the terms as stated above.

Shaun Burlingame, D.D.S., M.D. | Francisco Suarez, D.D.S. | Oral & Maxillofacial Surgery | Dental Implants | 316 Knollcrest Drive, Redding, CA 96002 | P 530-223-1811 | F 530-223-1813 | https://www.riversideos.com

Arbitration Agreement

Office Location: Riverside Oral Surgery – 316 Knollcrest Drive, Redding, CA 96002

Article 1: Agreement to Arbitrate

It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this Contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated

It is the intention and agreement of the parties that this arbitration agreement shall cover all claims or controversies relating to the matters described in Article 1 above, except claims within the jurisdiction of the Small Claims Court, whether in tort (intentional or negligent), contract, or otherwise, including but not limited to suits relating to the matters described in Article 1 and also involving claims for loss of consortium, wrongful death, discrimination, emotional distress or punitive damages. Arbitration pursuant to the terms of this Contract shall bind all parties whose claims as described in Article 1 may arise out of or in any way relate to treatment or services provided or not provided by Riverside Oral Surgery or any employee or agent or providers of Riverside Oral Surgery, including any spouse or heirs of Patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. The undersigned understands and agrees that if the undersigned signs this Contract on behalf of some other person for whom the undersigned has responsibility, then, in addition to the undersigned, such person(s) will also be bound, along with anyone else who may have a claim arising out of the treatment or services rendered to that person. The reference to Riverside OS includes the corporation, and its employees, agents and providers. Filing any action in any court by Riverside Oral Surgery to collect any fee from Patient shall not waive the right to compel arbitration of any claim described in Article 1. However, following the assertion of any claim against Riverside Oral Surgery, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by the same arbitration.

Article 3: Procedures and Applicable Law

Patient shall initiate arbitration by serving a Demand for Arbitration on Riverside Oral Surgery and each defendant. The claim shall be mailed by U.S. mail, postage prepaid, to: Bryan Elwood, 2901 Ashton Boulevard, Suite 210, Lehi, Utah 84043. A Demand for Arbitration must be communicated in writing to all parties, identify each defendant, describe the claim against each party, and the amount of damages sought, and the names, addresses and telephone numbers of the Patient and his/her attorney. Patient agrees that any arbitration hereunder shall be conducted by a single, neutral arbitrator selected by the parties and shall be resolved using the rules of the American Arbitration Association. (Arbitration, however, shall not be conducted by the American Arbitration Association.) Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Civil Code §§ 3333.1 and 3333.2, Code of Civil Procedure §§ 340.5, 667.7, 1281-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-9), as in effect from time to time.

Article 4: Retroactive Effect

Patient intends this Contract to cover services rendered by Riverside Oral Surgery not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Severability

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this Contract. By my signature below, I acknowledge that I have received a copy.

Notice: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article 1 of this contract.

(Signature of Patient, Parent, Guardian or Legally Authorized Representative of Patient) Riverside Oral Surgery

In consideration of the foregoing agreements under this Contract, Riverside Oral Surgery likewise agrees to be bound by the terms set forth in this Contract and to the rules specified in Article 3 above.

Patient Consent for Written Notes (California)

Our office uses a secure helper system during your visit to make accurate written notes. The system listens in real time and creates written notes for your dental chart.

  • No recording is kept. Only the written notes become part of your record.
  • The notes are stored securely, in compliance with HIPAA and California privacy laws.
  • You can ask questions at any time.
  • Saying “no” will not affect your treatment, care, or relationship with our office.
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