Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms.

Patient First Name

Required

Middle Initial

Patient Last Name

Required

Gender

Male Female

Required

Date of Birth

Required

Age

Social Security #

Address

City

State

ZIP Code

Email

Home Phone

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

Referral By First Name

Referral By Last Name

Dentist First Name

Dentist Last Name

Medical Doctor First Name

Medical Doctor Last Name

Referral Address

City

State

ZIP code

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

Home Phone

Cell Phone

Email

Address

City

State

ZIP Code

Insurance Information

Primary Dental Insurance Company

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Is this an Employer Health Insurance Plan?

Yes No

Employer ID #

Insurance Company Name

Business Telephone

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Purchased through Federal Website?

Yes No

By:

You Your Employer

Primary Medical Insurance Company

Medical Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Business Address

City

State

Zip Code

Is this an Employer Health Insurance Plan?

Yes No

Employer ID #

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Purchased through Federal Website?

Yes No

By:

You Your Employer

Health History

Height

Weight

Are you in good health?

Yes No

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

If yes, for what condition?

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

Yes No

If yes, please describe

Have you had an artificial joint replacement (knee, hip, shoulder, etc)?

Yes No

Have you had or do you have arteriosclerosis or any other heart condition?

Yes No

Chest pain upon exertion

Yes No

Shortness of breath after mild exercise

Yes No

Do your ankles swell

Yes No

Have you had or do you have any disease, drug or transplant operation that has depressed your immune system?

Yes No

Have you ever had treatment for a tumor, cancer, or growth?

Yes No

Have you ever had radiation therapy to head, neck, or jaws?

Yes No

Do you use marijuana?

Yes No

Frequency?

Do you smoke or chew tobacco?

Yes No

How Much?

Do you use alcohol?

Yes No

Per week?

Per month?

Have you had any serious trouble with previous dental treatment?

Yes No

If yes, please describe

Have you had or do you currently have the following:

Damaged heart valves?

Yes No

Artificial valves?

Yes No

Heart murmur?

Yes No

Rheumatic heart disease?

Yes No

Heart Attack?

Yes No

Angina

Yes No

High blood pressure?

Yes No

Stroke?

Yes No

Allergies (other than medications)?

Yes No

Asthma?

Yes No

Hay Fever?

Yes No

Lung Disease/COPD

Yes No

COVID 19

Yes No

Fainting spells/ Seizures?

Yes No

Thyroid problems?

Yes No

Arthritis or painful, swollen joints?

Yes No

Osteoporosis?

Yes No

Stomach ulcers or hyperacidity?

Yes No

Kidney trouble

Yes No

Tuberculosis?

Yes No

Epilepsy/ Neurological disorder?

Yes No

Difficulty opening & closing your mouth?

Yes No

Diabetes or hypoglycemia?

Yes No

Hepatitis A?

Yes No

Hepatitis B?

Yes No

Hepatitis C?

Yes No

Jaundice/ Liver disease?

Yes No

Sleep apnea?

Yes No

Migraines?

Yes No

AIDS/HIV?

Yes No

Herpes

Yes No

What kind?

Abnormal bleeding or disorder?

Yes No

Anemia?

Yes No

Blood transfusions?

Yes No

History of chemical dependency?

Yes No

History of alcohol dependency?

Yes No

Emotional disorder (depression, etc)?

Yes No

Autism or other Behavioral Disorders

Yes No

Contact lenses?

Yes No

Removable dental appliance?

Yes No

Do you have any condition or disease you think the doctor should know about?

Yes No

If yes, please describe

Medications

Are you taking any of the following?

Fosamax

Yes No

Aredia

Yes No

Actonel

Yes No

Prolia

Yes No

Boniva

Yes No

Reclast

Yes No

Zometa

Yes No

Are you taking blood thinners (including Aspirin)?

Yes No

Are you taking or have you ever taken medication for osteoporosis or been treated with chemotherapy?

Yes No

Please list all medications including diet pills, non-prescription, vitamins, homeopathic or natural remedies

Pharmacy Name

Address

Phone

Allergies/ Reactions

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

Local anesthetic?

Yes No

Iodine?

Yes No

Penicillin?

Yes No

Codeine?

Yes No

Other Antibiotics?

Yes No

If yes, please list:

Other Narcotics?

Yes No

If yes, please list:

Barbiturates or sleep pills?

Yes No

Latex or rubber products?

Yes No

Aspirin, Ibuprofen, Acetaminophen?

Yes No

Other

For Women Only

Are you pregnant or trying to become pregnant?

Yes No

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 have read and understand the above. I understand the importance of a truthful and complete Health History to assist in providing the best care possible. I hereby acknowledge that all information above is correct.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Required

Date

Required

Fees and Payments

We make every effort to keep down the cost of your oral surgical care. You can help by paying on 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 at the top of the 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 other 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. Any account over 90 days will be charged a 1-1/2% finance charge monthly with an annual rate of 18%, in addition to any collection agency fees and/or attorney fees and court costs incurred in the collection of outstanding balances.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist name of the insurance benefits otherwise payable to me.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

Somerset Oral & Maxillofacial Surgery Group Notice of Privacy Practices

I hereby acknowledge that I have reviewed a copy of this office's Notice of Privacy Practices. I give my permission to discuss this account to the following:

Name

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Required

Date

Required

If Patient is a Minor

Form signed by:

Relationship to Patient: