Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Driver's License #

Email

Address

City

State

Zip Code

Home Phone

Cell Phone

Marital Status

Employment Status

Full Time Part Time Retired Not Employed

Employer

Occupation

Business Phone

Student Status

Full Time Part Time Not a Student

School

School Address

City

State

Zip Code

Pharmacy

Pharmacy Telephone

Address

City

State

Zip Code

Have you ever been a patient in our practice?

Yes No

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

Yes No

Referred By First Name

Referred By Last Name

Referral Tel #

Dentist First Name

Dentist Last Name

Dentist Tel #

Primary Care Physician First Name

Primary Care Physician Last Name

Physician Tel #

Orthodontist First Name

Orthodontist Last Name

Orthodontist Tel #

Please list any other Specialists involved in your care.

Nearest relative not living with you First Name

Nearest relative not living with you Last Name

Relative Phone

Personal Payment Type

Cash Check Credit Card

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Age

Telephone

Address

City

State

Zip Code

Employer

Business Phone

Spouse or other guarantor information

Please check here if information is different from above

First Name

Last Name

SSN

Date of Birth

Relation

Telephone

Address

City

State

Zip Code

Employer

Business Phone

Emergency Contact

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Insurance Information

Is your insurance a PPO or HMO plan?

Yes No

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

Business Telephone

Insurance Company Name

Insurance Company 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

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

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

Business Telephone

Insurance Company Name

Insurance Company 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

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

Health History

Reason for today's office visit?

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

Do you require pre-medication?

Yes No

Please list medication

Have you had or do you currently have the following:

Rheumatic fever?

Yes No

Damaged heart valve?

Yes No

Mitral valve prolapse?

Yes No

Heart murmur?

Yes No

High blood pressure?

Yes No

Low blood pressure?

Yes No

Sycope (fainting)?

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

Chronic cough?

Yes No

Persistent swollen neck glands?

Yes No

Asthma?

Yes No

Hay fever?

Yes No

Sinus Infections?

Yes No

Snoring?

Yes No

Sleep apnea?

Yes No

Difficulty breathing?

Yes No

Other lung trouble?

Yes No

Tuberculosis?

Yes No

Emphysema?

Yes No

Do you smoke?

Yes No

How many packs/day?

Do you use chewing tobacco?

Yes No

Blood transfusion?

Yes No

Blood disorder/ anemia?

Yes No

Bleeding tendency?

Yes No

Easy Bruising

Yes No

Liver disease?

Yes No

Stomach ulcers?

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

Contagious diseases?

Yes No

Delay in healing?

Yes No

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 jaw/TMJ?

Yes No

Medications

Are you taking any of the following?

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

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Have you ever taken diet pills?

Yes No

Are you taking, or have you ever taken bone density medications, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast,
or Evista in the past 12 years?

Yes No

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

Allergies/ Reactions

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

Aspirin?

Yes No

Codeine?

Yes No

Penicillin?

Yes No

Other Antibiotic?

Yes No

If yes, please list:

Sulfa drugs?

Yes No

Local Anesthetic (Novacain)?

Yes No

Other Medications?

Yes No

Please list medication allergies

Latex?

Yes No

Soy?

Yes No

Egg/Yolk?

Yes No

Sulfites?

Yes No

Sodium pentothal, Valium, or other tranquilizers?

Yes No

Is there a family history of the following?

Cancer

Yes No

Heart disease

Yes No

Diabetes

Yes No

Anesthetic problems

Yes No

Is this visit related to an accident?

Yes No

Date of Injury

Please check all that apply

Automobile

Work Related

Other

Insurance company handling this claim

Claim Number

Name of Attorney/ Adjustor

Telephone

For Women Only

Is there a possibility of pregnancy?

Yes No

Trimester

First Second Third

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.

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.

Signature of Patient (or legal guardian)

Clear

Clear

Date

Fees and Payments

For your convenience, we accept cash, Certified Check/Personal Checks $500.00 or less, Visa, MasterCard, American Express, Discover, Care Credit and most insurance plans. Personal checks that are returned due to “insufficient funds” are subject to a $50.00 service fee. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time services are rendered. All accounts over 90 days will be considered past due. Patient agrees to pay additional charges of 18% of 1.5 monthly finance charges (or the maximum percentage allowed by law, whichever is lower) of the invoiced amount per month for any payment received by Reston Advanced Oral & Cosmetic Facial Surgery, and affiliates or employees representing or d/b/a Reston Advanced Oral & Cosmetic Facial Surgery more than 90 days from the date of invoice or bill for services. In the event collection of patient’s account is referred to an attorney, patient agrees to pay all expenses incurred by Reston Advanced Oral & Cosmetic Facial Surgery, and affiliates or employees representing or d/b/a/ Reston Advanced Oral & Cosmetic Facial Surgery in effecting payment, specifically including attorney’s fees of 33-1/3% of the principal due and owing. If you have questions regarding your account, please contact us at (571) 595-3223. Many times, a simple telephone call will clear any misunderstandings.

Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage. We will send you a monthly statement. We ask that you also realize that we do not work for an insurance company. Rather we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you receive every benefit allotted in your insurance contract. However; the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.

If you need to cancel or reschedule your appointment, please call us 48 hours in advance. If you fail to do so, or are not present at your scheduled appointment, there will be a $500.00 charge.

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.

HIV/Hepatitis B or C Testing

As a patient, please be advised that in accordance with Section 32.1-45.1 of the Code of Virginia, 1950, as amended, that if the provision of health care services to the patient exposes any person employed by or under the direction and control of this facility or any other healthcare provider, to the patient's body fluids in a manner which may transmit immunodeficiency virus or HIV or Hepatitis B or C viruses, then the patient will be deemed to have consented to testing for infection with HIV or Hepatitis B or C viruses, and the release of such test results to the person(s) exposed.

Privacy Policy

Click on the hyperlink to obtain a copy:

Reston Advanced Oral & Cosmetic Facial Surgery Privacy Practices

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.

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.

Signature of Patient (or legal guardian)

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient: