Patient Registration

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Preferred Name

Pronoun

Gender

Male Female Non-Binary

Birth Date

Age

Social Security #

Driver's License #

E-mail

Address

City

State

ZIP Code

Telephone

Cell Phone

Marital Status

Employment Status

Full Time Part Time Retired Not Employed

Employer

Business Telephone

Student Status

Full Time Part Time Not a Student

School Name

School Address

City

State

ZIP Code

Have you ever been a patient of our practice?

Yes No

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

Yes No

Referred By

Referral Tel #

Dentist

Dentist Tel #

Medical Doctor

Medical Doc Tel #

Orthodontist

Orthodontist Tel #

Preferred Pharmacy

Pharmacy Tel #

Nearest relative not living with you

Telephone

Personal Payment Type

Cash Check Credit Card

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

Other

Responsible Person First Name

Responsible Person Last Name

Social Security #

Birth Date

Age

Telephone

Address

City

State

ZIP Code

Employer

Business Telephone

Spouse or other guarantor information

Please check here if information is different from above

First Name

Last Name

Social Security #

Relation

Birth Date

Telephone

Address

City

State

ZIP Code

Employer

Business Telephone

EMERGENCY CONTACT

First Name

Last Name

Home Telephone

Work Telephone

Cell Phone

INSURANCE INFORMATION

PRIMARY DENTAL INSURANCE COMPANY

Primary Policy Holder

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

ZIP Code

Business Telephone

Insurance Co. Name

Insurance Co. Address

City

State

ZIP Code

Telephone

Policy I.D. #

Group #

Group Name

SECONDARY DENTAL INSURANCE COMPANY

Do you have secondary dental insurance?

Yes No

Secondary Policy Holder

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

ZIP Code

Business Telephone

Insurance Co. Name

Insurance Co. Address

City

State

ZIP Code

Telephone

Policy I.D. #

Group #

Group Name

PRIMARY MEDICAL INSURANCE COMPANY

Medical Policy Holder

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP Code

Telephone

Policy Holder Employer

Business Address

City

State

ZIP Code

Business Telephone

Insurance Co. Name

Insurance Co. Address

City

State

ZIP Code

Telephone

Policy I.D. #

Group #

Group Name

SECONDARY MEDICAL INSURANCE COMPANY

Do you have secondary medical insurance?

Yes No

Secondary Medical Policy Holder

Relation

Gender

Male Female

S.S. #

Birth Date

Address

City

State

ZIP Code

Telephone

Policy Holder Employer

Business Address

City

State

ZIP Code

Business Telephone

Insurance Co. Name

Insurance Co. Address

City

State

ZIP Code

Telephone

Policy I.D. #

Group #

Group Name

HEALTH HISTORY

Reason for today's office 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

If yes, please describe

Are you under the care of a physician?

Yes No

Date of Last Visit

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

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 (artificial) joint?

Yes No

If yes, please describe location and date

Do you have an artificial heart valve?

Yes No

Have you had or do you currently have the following:

Rheumatic fever?

Yes No

Damaged heart valves/ mitral valve prolapse?

Yes No

Heart murmur?

Yes No

High blood pressure?

Yes No

Low blood pressure?

Yes No

Chest pain/ angina?

Yes No

Irregular heart beat?

Yes No

Cardiac pacemaker?

Yes No

Heart surgery?

Yes No

Heart attack?

Yes No

Pneumonia, bronchitis?

Yes No

Asthma?

Yes No

Hay fever/ sinus problems?

Yes No

Sleep apnea/ snoring?

Yes No

Difficulty breathing?

Yes No

Tuberculosis?

Yes No

Emphysema?

Yes No

Do you smoke or vape?

Yes No

If yes, how many packs per day?

Do you use chewing tobacco?

Yes No

Do you use marijuana or edibles?

Yes No

Blood transfusions?

Yes No

Blood disorder/ anemia?

Yes No

Bleeding tendency?

Yes No

Easy bruising?

Yes No

Hepatitis/ liver disease?

Yes No

Infectious mononucleosis?

Yes No

Gallbladder trouble?

Yes No

Convulsions/ seizures/ epilepsy?

Yes No

Stroke?

Yes No

Fainting spells?

Yes No

Thyroid trouble?

Yes No

Diabetes?

Yes No

Low blood sugar?

Yes No

Kidney trouble?

Yes No

Are you on dialysis?

Yes No

Arthritis/ joint disease?

Yes No

Osteoporosis/ osteopenia?

Yes No

Osteonecrosis?

Yes No

Stomach ulcers?

Yes No

Contagious diseases?

Yes No

Sexually transmitted diseases?

Yes No

Immunosuppressed?

Yes No

Problems with immune system?

Yes No

Delay in healing?

Yes No

A tumor or growth?

Yes No

Radiation or chemotherapy?

Yes No

Chronic fatigue/night sweats?

Yes No

Are you on a diet?

Yes No

A history of drug abuse?

Yes No

A history of alcohol abuse?

Yes No

Contact lenses?

Yes No

Eye disease/ glaucoma?

Yes No

Mental health problems?

Yes No

Removable dental appliance?

Yes No

Pain, clicking of jaws/TMJ?

Yes No

Malignant hyperthermia?

Yes No

MEDICATIONS

Are you taking any of the following?

Any kind of medication, drug, pills?

Yes No

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginkgo biloba)?

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Have you ever taken diet pills?

Yes No

Any bone density medication/ bisphosphonates (Aredia, Zometa, Fosamax, Actonel)?

Yes No

Have you ever taken tranquilizers, sleeping pills, antidepressants, 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 med)?

Yes No

Codeine or other narcotics?

Yes No

Penicillin?

Yes No

Other medications?

Yes No

Other antibiotic?

Yes No

Latex?

Yes No

Sulfa drugs?

Yes No

Soy?

Yes No

Sodium pentothal, Valium, or other tranquilizers?

Yes No

Eggs/ yolk?

Yes No

Aspirin?

Yes No

Sulfites?

Yes No

Please list any allergies other than drug allergies:

FOR WOMEN ONLY

Is there a possibility of pregnancy?

Yes No

If yes, which trimester?

First Second Third

Expected Delivery

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.

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

Required

Date:

FEES AND PAYMENTS

We make every effort to keep down the cost of your oral surgical 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 for 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 any questions I may have regarding this Notice.

Click on the hyperlink to obtain a copy:

Davis Oral Surgery & Implant Center Privacy Practices

AUTHORIZATION

I authorize my surgeon and his/her 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.

OFFICE POLICIES ACKNOWLEDGEMENT

I certify that I have read and understand the office policies regarding Fees & Payments, Privacy Policy and Authorization as stated above. All of my questions have been answered to my satisfaction.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Required

Date:

IF PATIENT IS A MINOR

Form signed by:

Relationship to Patient: