Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms. Dr.

Patient Legal First Name

Required

MI

Patient Last Name

Required

Gender

Male Female Other

Required

Date of Birth

Age

Social Security #

Other

Address

City

State

Zip Code

Preferred Name

Home Phone

Cell Phone

Email

Preferred Form of Contact

Marital Status

Employment Status

Full Time Part Time Retired Not Employed

Employer

Business Telephone

Address

City

State

Zip Code

Student Status

Full Time Part Time Not a Student

School Name

Dentist First Name

Dentist Last Name

Dentist Tel #

Medical Doctor First Name

Medical Doctor Last Name

Medical Doc Tel #

Orthodontist First Name

Orthodontist Last Name

Orthodontist Tel #

Referred By First Name

Referred By Last Name

Preferred Pharmacy

Required

Address

City

Height

Required

Weight

Required

Emergency Contact

First Name

Last Name

Primary Telephone

Relationship to Patient

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

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Primary Medical Insurance Company

Medical Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Do you have secondary insurance?

Yes No

If yes, is it:

Medical Dental

Primary Policy Holder

Relation

SSN

Date of Birth

Secondary Insurance Co.

Policy I.D. #

Insurance Company Address

City

State

Zip Code

Telephone

Health History

Please answer the following questions carefully and honestly. The information you provide is confidential and will assist us in providing you the best possible care. Please explain any YES answers.

Do you smoke, chew tobacco or vape?

Yes No

Per day?

Per week?

Do you smoke marijuana?

Yes No

Per day?

Per week?

Do you use alcohol?

Yes No

Per day?

Per week?

Hospitalizations and/or prior surgeries from childhood forward?

Yes No

If yes, please describe when/why

Reactions to any type of anesthesia?

Yes No

If yes, please describe

Any condition you wish to speak privately about with the Doctor?

Yes No

Any disease or treatment that has lowered your immune system?

Yes No

Any form of cancer?

Yes No

Any unpleasant effect from previous dental care?

Yes No

Are you required to pre-medicate with an antibiotic prior to dental treatment?

Yes No

If yes, please state why

Medications

Please list all current prescription medications, non-prescription medications, vitamins, herbal supplements.

Allergies/ Reactions

Please list any allergies such as latex, codeine, penicillin, Novocain, tape, soy, eggs, nuts.

For Women Only

Is there a possibility you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Are you taking hormone replacement?

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.

Have you had or do you currently have the following:

Anemia

Yes No

Anxiety

Yes No

Appetite Disorder

Yes No

Arthritis

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Bleeding Disorder

Yes No

Bronchitis

Yes No

Chest Pain/Tightness

Yes No

Chicken Pox

Yes No

Chronic Nasal Congestion

Yes No

Coumadin/Blood Thinners

Yes No

Depression

Yes No

Diabetes

Yes No

Diet Pills

Yes No

Dislocated Joints

Yes No

Dizziness

Yes No

Earache(s)

Yes No

Emphysema

Yes No

Fainting Spells

Yes No

Fractured Bones

Yes No

Gags Easily

Yes No

Glaucoma

Yes No

Headaches

Yes No

Hearing Changes

Yes No

Heart Murmur

Yes No

Heart Disease

Yes No

Heart Rhythm Changes

Yes No

Heart Valve Replacement

Yes No

Heart Vessel Blockage

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

Hepatitis C

Yes No

High Blood Pressure

Yes No

HIV

Yes No

Hoarseness

Yes No

HPV

Yes No

Intestinal Disorder

Yes No

Jaw Joint Pain/Noise

Yes No

Liver Disorder

Yes No

Measles

Yes No

Mitral Valve Prolapse

Yes No

Mumps

Yes No

Nervous System Disorder

Yes No

Night Sweats

Yes No

Osteoporosis Medication

Yes No

Pneumonia

Yes No

Psychiatric Treatment

Yes No

Radiation Therapy

Yes No

Recent Fevers

Yes No

Recurrent Mouth Sores

Yes No

Seizures

Yes No

Shortness of Breath

Yes No

Sinus Disorders

Yes No

Sleep Apnea

Yes No

Snoring

Yes No

Stomach Ulcers

Yes No

Thyroid Disease

Yes No

Treated for Alcohol Dependency

Yes No

Treated for Drug Dependency

Yes No

Treated for Eating Disorder

Yes No

Treated for Sexually Transmitted Disease

Yes No

Tuberculosis

Yes No

Unexplained Weight Loss

Yes No

Vitamin Deficiency

Yes No

Wear Glasses/Contacts

Yes No

Please explain any YES answers or other medical problems not mentioned.

Form Completion

I honestly and accurately attest to the above medical history and authorize the release of this medical information, as necessary, for my treatment.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Required

If Patient is a Minor

Form signed by:

Relationship to Patient:

ACKNOWLEDGMENT OF ANESTHESIA & MEDICATION USE IN YOUR CARE

I acknowledge that certain medications that may be prescribed to me by my doctor at Northeast Oral Surgery and Dental Implant Center may alter my state of mental awareness and decision making. Depending on the type of anesthetic given, I understand the importance of adhering to the following:

• Refrain from driving a car.
• Refrain from operating machinery of any kind.
• Refrain from making important personal or business decisions.
• Refrain from drinking alcohol of any kind.
• Refrain from taking sedatives (prescribed by another doctor or over-the-counter).
• Refrain from taking different medications at the same time. To avoid nausea, wait 30-60 minutes between taking each medication.

Initials

PATIENT FINANCIAL POLICY

Please initial your understanding and acknowledgment of this policy below.

By initialing below, I agree to the terms of the Patient Financial Policy document.

Click on the hyperlink to obtain a copy:

Financial Policy

Initials

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

Northeast Oral Surgery Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 establishes an individual’s right to access and receive copies for their Protected Health Information (PHI). Additionally, this act provides for an individual to designate person(s) they are associated with, such as parent, guardian, spouse, child, etc. (this is in addition to their personal physician or dentist) to have access to their PHI. 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 of Designated Person

INSURANCE REFERRAL WAIVER

Please initial your understanding and acknowledgment of this policy below.

I have been informed by Northeast Oral Surgery and Dental Implant Center that based on the rules and regulations of my insurance policy; it is my responsibility to have a referral in place with my medical insurance company from my primary care physician.

I understand that if I do not have a referral in place, claims submitted by Northeast Oral Surgery and Dental Implant Center may not be paid and will be my financial responsibility.

Initials

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Required

Date

Required

If Patient is a Minor

Form signed by:

Relationship to Patient: