Patient Registration

Mr. Mrs. Ms. Dr.

Patient First Name

M.I.

Patient Last Name

Sex

Male Female

Birth Date

Age

Social Security #

Home Phone

Cell Phone

Email

Address

City

State

ZIP Code

Marital Status

Driver's License #

Nearest relative not living with you

Telephone

Employment Status

Full Time Part Time Retired Not Employed

Employer

Business Telephone

Have you ever been a patient of our practice?

Yes No

Has a family member ever been a patient of our practice?

Yes No

Personal Payment Type

Cash Check Credit Card

Referred By

Orthodontist

Dentist

Medical Doctor

Emergency Contact

First Name

Last Name

Telephone

Relation

Who will be responsible for your account? (if self is selected, please skip to next section)

Other

First Name

Last Name

Social Security #

Birth Date

Age

Telephone

Cell Phone

Email

Driver's License #

Address

City

State

ZIP Code

Employer

Business Telephone

Spouse or other guarantor information (if different from above)

First Name

Last Name

Social Security #

Relation

Birth Date

Telephone

Address

City

State

ZIP Code

Employer

Business Telephone

INSURANCE INFORMATION

Do you have insurance?

Yes No

Is your insurance a PPO or HMO plan?

Yes No

PRIMARY DENTAL INSURANCE COMPANY

Employer

Bus. Address

City

State

ZIP

Bus. Phone

Plan

Ins. Co. Name

ID#

Address

City

State

ZIP

Telephone

Group Name

Group #

Insured Party

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP

Telephone

PRIMARY MEDICAL INSURANCE COMPANY

Employer

Bus. Address

City

State

ZIP

Bus. Phone

Plan

Ins. Co. Name

ID#

Address

City

State

ZIP

Telephone

Group Name

Group #

Insured Party

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP

Telephone

HEALTH HISTORY

Although oral surgeons 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 medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's visit?

Are you in good health?

Yes No

Height

Weight

Have there been any changes to your general health in the past year?

Yes No

Are you under the care of a physician?

Yes No

Date of Last Visit

If so, for what are you being treated?

Have you had any illness, operation, or have been hospitalized in the past?

Yes No

If yes, please describe

Do you have unhealed/recurrent injuries, ulcers, inflamed areas, growths or sore spots in or around your mouth?

Yes No

If yes, please describe where

Do you have a prosthetic joint/implant?

Yes No

If so, describe where

Have you had a heart valve replacement or vascular graft?

Yes No

Have you ever had general anesthesia?

Yes No

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Yes No

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

Have you had, or do you currently have, any of the following:

Rheumatic fever?

Yes No

Damaged heart valves / mitral valve prolapse?

Yes No

Chest pain / angina?

Yes No

High blood pressure?

Yes No

Low blood pressure?

Yes No

Cardiac pacemaker?

Yes No

Heart attack(s)?

Yes No

Irregular heart beat?

Yes No

Difficulty breathing / other lung trouble?

Yes No

Heart surgery?

Yes No

Pneumonia, bronchitis, chronic cough?

Yes No

Sleep apnea / CPAP?

Yes No

Hay fever / sinus problems?

Yes No

Snoring?

Yes No

Emphysema?

Yes No

Asthma?

Yes No

Tuberculosis?

Yes No

Do you use chewing tobacco?

Yes No

Do you smoke?

Yes No

If yes, how many packs per day?

Bruise easily?

Yes No

Blood transfusion?

Yes No

Blood disorder / anemia?

Yes No

Infectious mononucleosis?

Yes No

Bleeding tendency / abnormal bleeding?

Yes No

Hepatitis, jaundice, or liver disease?

Yes No

Convulsions / epilepsy?

Yes No

Gallbladder trouble?

Yes No

Fainting spells?

Yes No

Diabetes?

Yes No

Stroke?

Yes No

Thyroid trouble?

Yes No

High cholesterol?

Yes No

Low blood sugar?

Yes No

Kidney trouble?

Yes No

Stomach / Gl troubles / ulcers / IBS / colitis?

Yes No

Are you on dialysis?

Yes No

Swollen ankles / arthritis / joint disease?

Yes No

Osteonecrosis?

Yes No

Acid reflux?

Yes No

Osteoporosis / Osteopenia?

Yes No

Problems with immune system? Possibly from medication / surgery, etc.

Yes No

Contagious diseases?

Yes No

Sexually transmitted diseases?

Yes No

Cancer / radiation therapy / chemotherapy?

Yes No

Delay in healing?

Yes No

Chronic fatigue / night sweats?

Yes No

History of alcohol abuse?

Yes No

A tumor or growth?

Yes No

Contact lenses?

Yes No

Eye disease / glaucoma?

Yes No

History of drug abuse?

Yes No

Removable dental appliance?

Yes No

Pain or clicking of jaws when eating?

Yes No

Mental health problems / anxiety / depression?

Yes No

Heart murmur?

Yes No

WOMEN ONLY

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

MEDICATIONS

Are you taking any of the following?

Any kind of medication, drug, pills?

Yes No

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Gingko biloba, Aggrenox, Pradaxa, Fish oil)?

Yes No

Have you ever taken diet pills?

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Are you taking, or have you ever taken, bone density meds or bisphosphonates such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or Reclast in the past 12 years?

Yes No

Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?

Yes No

If so, please list

Please list any other medications you are currently taking (medication name, dosage and frequency):

ALLERGIES/REACTIONS

Are you allergic to, or had a reaction to any of the following:

Local anesthetic (numbing meds)?

Yes No

Penicillin?

Yes No

Other antibiotics?

Yes No

Sulfa drugs?

Yes No

Sodium pentothal / Valium / other tranquilizers?

Yes No

Aspirin?

Yes No

Amoxicillin?

Yes No

Codeine or other narcotics?

Yes No

Latex?

Yes No

Soy?

Yes No

Eggs / yolk?

Yes No

Sulfites?

Yes No

Do you have known allergies?

Yes No

Please list any allergies other than drug allergies:

Please list any other medication or antibiotic you are allergic to:

Is there a family history of the following:

Cancer?

Yes No

Heart disease?

Yes No

Diabetes?

Yes No

Anesthetic problems?

Yes No

VISIT RELATED TO AN ACCIDENT

Is this visit related to an accident?

Yes No

If yes, please check all that apply

Automobile Work Related Other

Date of Injury

Insurance company handling this claim

Claim Number

Name of Attorney/Adjustor

Telephone

FORM COMPLETION

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date:

FEES AND PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company. You will be responsible for all collection costs, attorney fees and court costs.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

PRIVACY POLICY

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask questions I may have regarding this Notice.

AUTHORIZATION

I authorize my surgeon and his/her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and/or mobile phone concerning my appointment.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date:

Witness:

Clear

Clear

Doctor:

Clear

Clear

IF PATIENT IS A MINOR

Form signed by:

Relationship to Patient: