Patient Registration

Patient First Name

Middle Initial

Patient Last Name

Preferred Name/Nick Name

Preferred Gender Pronoun

Birth Date

Age

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Address

Apt#

City

State

ZIP Code

Email

Home Phone

Cell Phone

Marital Status

Employment Status

Employer

Work Telephone

Student Status

Full Time Part Time Not a student N/A

School Name

School Address

City

State

Zip Code

Emergency Contact

First Name

Last Name

Phone

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

Self Spouse Parent Other

Other

First Name

Last Name

Birth Date

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Is address the same as patient?

Yes No

Address

Apt#

City

State

Zip Code

Email

Home Phone

Cell Phone

Is the patient a minor?

Yes No

Name of legal guardian:

If not listed above, please provide legal guardian’s phone number & address

Phone #

Address

Does the patient have a decision-making capacity? (If no, provide name & phone number of the patient’s legal representative or health care power of attorney who we can contact to obtain consent for treatment)

Yes No

Name

Phone #

Does the patient require any special accommodations such as language interpretation (including American sign language), accommodations for service animals, accessibility, …etc.?

Yes No

If yes, please list accommodations requested

INSURANCE INFORMATION

Do you have dental insurance?

Yes No

PRIMARY DENTAL INSURANCE COMPANY

Primary Policy Holder

Primary Policy Holder’s Relationship to Patient

Self Other

Please specify relationship: spouse, parent, etc.

If self, or listed above, please skip to insurance company information.

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Birth Date

Email

Phone

Address

Apt #

City

State

ZIP

Insurance Co. Name

Phone

Is this an Employer Health Insurance Plan?

Yes No

If yes: Primary Policy Holder Employer

Group #

Member ID # (Policy #)

Purchased through Federal Website?

Yes No

By:

You Your Employer

Do you have secondary dental insurance?

Yes No

SECONDARY DENTAL INSURANCE COMPANY (if applicable)

Primary Policy Holder

Primary Policy Holder’s Relationship to Patient

Self Other

Please specify relationship: spouse, parent, etc.

If self, or listed above, please skip to insurance company information.

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Birth Date

Email

Phone

Address

Apt #

City

State

ZIP

Insurance Co. Name

Phone

Is this an Employer Health Insurance Plan?

Yes No

If yes: Primary Policy Holder Employer

Group #

Member ID # (Policy #)

Purchased through Federal Website?

Yes No

By:

You Your Employer

Do you have medical insurance?

Yes No

PRIMARY MEDICAL INSURANCE COMPANY

Primary Policy Holder

Primary Policy Holder’s Relationship to Patient

Self Other

Please specify relationship: spouse, parent, etc.

If self, or listed above, please skip to insurance company information.

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Birth Date

Email

Phone

Address

Apt #

City

State

ZIP

Insurance Co. Name

Phone

Is this an Employer Health Insurance Plan?

Yes No

If yes: Primary Policy Holder Employer

Group #

Member ID # (Policy #)

Purchased through Federal Website?

Yes No

By:

You Your Employer

Do you have secondary medical insurance?

Yes No

SECONDARY MEDICAL INSURANCE COMPANY (if applicable)

Primary Policy Holder

Primary Policy Holder’s Relationship to Patient

Self Other

Please specify relationship: spouse, parent, etc.

If self, or listed above, please skip to insurance company information.

SSN

If you prefer to provide this information over the phone or in person, you can leave this area blank

Birth Date

Email

Phone

Address

Apt #

City

State

ZIP

Insurance Co. Name

Phone

Is this an Employer Health Insurance Plan?

Yes No

If yes: Primary Policy Holder Employer

Group #

Member ID # (Policy #)

Purchased through Federal Website?

Yes No

By:

You Your Employer

FINANCIAL POLICY/ FEES AND PAYMENTS

Accepted forms of payment:

For your convenience, we accept payment in the form of check, debit card, credit card (Visa, MasterCard, Discover, or American Express). We also accept Apple pay and Samsung pay. All payments for any oral and maxillofacial surgery services are due before or at the time of service.

Insurance policy:

To help maximize benefits available to you from your insurance plan or benefits carrier, Community Oral and Maxillofacial Surgery is committed to submitting claims and filing any necessary supplementary material to your dental benefits carrier and/or medical insurance provider for services rendered to you. Every attempt to successfully submit claims on your behalf will be made by our team. Please complete the insurance section above to assist us in this effort and notify us immediately of any changes in your insurance coverage.

Please note that benefits payable for procedures vary depending on the coverage provided by your plan. Our team may be able to provide you with an estimate of this coverage amount or percentage. If you have concerns regarding your coverage, we encourage you to contact your insurance carrier directly. Community Oral and Maxillofacial Surgery makes no guarantee of coverage or payment by a third party.

Please note that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance companies or benefits carriers pay a fixed allowance 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 that is not paid for by your insurance company. These payments are due before or at the time of service.

Deposits and Cancelled Appointments:

Procedures that require an advanced order of materials or medications may require a deposit to be collected at the time that your appointment is scheduled. If any of these orders are custom made to you, we will not be able to return them and they will be wasted. Payment for these materials and medications will be collected at the time your appointment is scheduled. Failure to show up for the appointment or a cancellation will result in the forfeiture of all or part of the deposit that you made.

We require at least 48 hours’ notice for appointment cancellations. Failure to show for the appointment may result in a cancellation fee.

By signing below:

- I acknowledge that I have read and understand the financial policies listed above, and
- I authorize the release of the necessary information required by my insurance/benefits provider to process my dental/medical insurance claims, and
- I authorize insurance and benefits payments to be made directly to Community Oral and Maxillofacial Surgery

Patient Signature (Parent, Legal Guardian, Healthcare Power of Attorney)

Clear

Clear

Required

Date

IF PATIENT IS NON-DECISIONAL OR IS A MINOR

Form signed by

Relationship to Patient

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have reviewed a copy of this office's Notice of Privacy Practices.

Please click on the hyperlink: Notice of Privacy Practices

I give my permission to discuss this account to the following:

1.

2.

3.

Patient Signature (Parent, Legal Guardian, Healthcare Power of Attorney)

Clear

Clear

Required

Date

HEALTH HISTORY

An accurate and complete health history will assist in coordinating your dental care. Please speak with a clinical team member if there are any questions about this form.

Height (ft)

Weight (lbs) (used to calculate medication dosages)

What brings you to our clinic today?

Referred By

Phone

Primary Dentist (if other than referral)

Phone

Primary Care Physician

Phone

Date of last physical exam

Other than those listed above, are you being seen by any other health care providers?

Yes No

List any other providers and phone numbers here

What conditions are they treating you for?

How would you describe your overall health?

Excellent Good Fair Poor

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

Yes No

If yes, please describe

Have you ever been hospitalized or had a serious illness if not listed above?

Yes No

If yes, please describe

Have you ever had a surgery?

Yes No

If yes, please describe

Have you been informed that you need antibiotics prior to dental procedures?

Yes No

If yes, why?

What type of antibiotics?

Name of prescribing provider

Phone

Have you had a joint replacement or implant?

Yes No

Date of replacement

Month/Year of Replacement

Joint replaced

Have you ever had a heart valve replacement?

Yes No

Date of replacement

Month/Year of Replacement

Have you, or any of your immediate family members, had any serious or unusual reactions to general anesthesia?

Yes No

If yes, please describe

MEDICATIONS

Are you taking any of the following? If yes, please list name, dose & frequency in the table below. For intravenous medications, please provide date of most recent infusion & provide prescribers information.

Blood thinners (including Aspirin, Plavix, Vitamin E, Xarelto, Eliquis, Pradaxa, Coumadin)? If yes, please describe in medication table.

Yes No

Natural supplements or homeopathic remedies? If yes, please describe in medication table.

Yes No

Do you currently take, or have you ever taken any of the following medications (usually used for bone density, adjuvant therapies in cancer treatment, and for some inflammatory diseases): Boniva, Fosamax, Aredia, Prolia, Actonel, Xgeva, Zometa, Nexavar, Sutent, Sirolimus (Rapamune), Humira, Infliximab, Avastin?

Yes No

If yes, which medication

Frequency

Last Dose

Prescribing provider

Please list all medications that you are currently taking below:

Medication

Dose (Amount)

Frequency

What are you taking the medication for?

Please list additional prescription or non-prescription medications, including the dosage and reason for taking:

Are you under the care of a health care provider for pain management or for recovery from a substance use disorder?

Yes No

Name of health care provider/clinic

Phone

Are you on a pain contract?

Yes No

What medications are you on for management of pain or recovery from substance use?

Other

Do you have, or have you ever had, any of the following conditions:

Rheumatic fevers?

Yes No

Notes

Congenital heart disease?

Yes No

Notes

Damaged heart valves/mitral valve prolapse/heart murmur?

Yes No

Notes

Chest pain/angina?

Yes No

Notes

Heart attacks?

Yes No

Notes

Irregular heartbeat?

Yes No

Notes

Cardiac pacemaker?

Yes No

Notes

Assisted ventricular device?

Yes No

Notes

Heart surgery?

Yes No

Notes

Heart transplant?

Yes No

Notes

Heart failure?

Yes No

Notes

High blood pressure?

Yes No

Notes

High cholesterol?

Yes No

Notes

Stroke?

Yes No

Notes

Sleep apnea?

Yes No

Notes

If yes, do you use a CPAP machine?

Yes No

Notes

Asthma?

Yes No

Notes

Hay fevers/sinus problems?

Yes No

Notes

Shortness of breath?

Yes No

Notes

COPD or emphysema?

Yes No

Notes

Immune system problems?

Yes No

Notes

HIV or AIDS?

Yes No

Notes

Autoimmune disorders (such as Lupus, Myasthenia gravis, Psoriasis)?

Yes No

Notes

Multiple sclerosis?

Yes No

Notes

If yes, when was this diagnosed?

History of organ transplant or bone marrow transplant?

Yes No

Notes

Contact lenses?

Yes No

Notes

Eye disease/glaucoma?

Yes No

Notes

Delay in healing?

Yes No

Notes

Blood disorders (such as anemia or thalassemia)?

Yes No

Notes

Easy bleeding or bruising?

Yes No

Notes

Bleeding disorders (such as hemophilia or von willebrand’s disease)?

Yes No

Notes

Liver disease?

Yes No

Notes

Hepatitis or jaundice?

Yes No

Notes

Fainting spells?

Yes No

Notes

Convulsions/seizures/epilepsy?

Yes No

Notes

Diabetes?

Yes No

Notes

Kidney problems?

Yes No

Notes

Are you on dialysis?

Yes No

Notes

If yes, which days?

Osteoporosis/osteopenia?

Yes No

Notes

Thyroid disease?

Yes No

Notes

Other endocrine disease?

Yes No

Notes

Arthritis?

Yes No

Notes

Crohn’s disease/ulcerative colitis?

Yes No

Notes

Acid reflux/GERD/stomach ulcers?

Yes No

Notes

Cancer/radiation therapy/chemotherapy?

Yes No

Notes

Chronic fatigue/night sweats?

Yes No

Notes

Chronic pain? If so, please answer questions below.

Yes No

Notes

Substance use disorder (including alcohol, heroin, opiods, cocaine)? If so, please complete questions above.

Yes No

Notes

Eating disorder (Bulimia nervosa or anorexia nervosa)?

Yes No

Notes

ADHD/ADD?

Yes No

Notes

Autism spectrum disorder?

Yes No

Notes

Anxiety or depression?

Yes No

Notes

Other psychiatric disorder?

Yes No

Notes

History of radiation therapy to the head and neck?

Yes No

Notes

If yes, please provide dates & hospital/provider that cared for you at that time

Any other medical conditions not listed above?

Yes No

If yes, please describe

Female Patients

Are you pregnant?

Yes No

If yes, how many weeks?

Name of OB provider

Phone

Are you nursing?

Yes No

If yes, how old is your child?

How much do they weigh?

Are you taking any birth control pills?

Yes No

Please note that antibiotics (such as Penicillin) may alter the effectiveness of birth control pills. Consult with your physician/OB/GYN about additional methods of birth control.

ALLERGIES/REACTIONS

Please list any medications that you are allergic to:

Medication

Reaction

Please list any foods or drinks that you are allergic to (include allergies to eggs and/or soy):

Food/Drink

Reaction

Do you have an allergy to Latex?

Yes No

If yes, what reaction did you have when in contact with Latex

Please list other allergies here:

Have you ever or do you currently use any tobacco products (cigarettes, cigars, vaping, chewing, pouching)?

Yes No

If yes, how much per day?

What year did you start?

End?

Do you drink alcohol?

Yes No

If yes, type and number of drinks

Per

Day Week Month

Do you use marijuana?

Yes No

If yes, amount

Per

Day Week Month

Have you ever or do you currently use cocaine or heroin?

Yes No

If yes, how frequently?

When was the last time you used cocaine or heroin?

Have you completed treatment for a substance use disorder?

Yes No

When did you complete the treatment?

FAMILY HISTORY

Does anyone in your family have a history of:

Bleeding disorder

Yes No

Heart disease

Yes No

Cancer

Yes No

Lung disease

Yes No

Other family history

Yes No

Please explain

Are there any other medical conditions or concerns that you would like to discuss with the team?

Yes No

Is there anything you would like to discuss with the doctor in private?

Yes No

FORM COMPLETION

I understand the importance of a truthful and complete health history to assist my health care team in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

Patient Signature (Parent, Legal Guardian, Healthcare Power of Attorney)

Clear

Clear

Required

Date

IF PATIENT IS NON-DECISIONAL OR IS A MINOR

Form signed by

Relationship to Patient