Location
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Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?
Personal Payment Type
If self, skip this section
Student
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Employed
Do you belong to a PPO or HMO?
Primary Dental Insurance
Secondary Dental Insurance
Primary Medical Insurance
Secondary Medical Insurance
To our patients,
Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving.
Additionally, our training and experience go well beyond what most people think of when they think about what we do as oral surgeons.
Essentially, we can improve the quality of your life, but also your confidence and smile. We want to take a moment to understand you and your desires. Thank you for answering the following questions; your answers are for our records only and are confidential.
Are you in good health?
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Have you had any illness, operation, or been hospitalized in the past 5 years?
Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots in or around your mouth?
Do you have a prosthetic joint or implant?
Have you had a heart valve replacement or vascular graft?
Have you ever had general anesthesia?
Have you, or a family member, had any unusual or serious reactions to general anesthesia?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Is it causing any pain of sensitivity?
Is it impacting your ability to eat what you like?
Is there anything that makes you feel self-conscious that we could assist with you?
Have you talked to any other doctors about your concern in the past?
Rheumatic fever?
Damaged heart valves/mitral valve prolapse?
Heart Murmur
High blood pressure?
Low blood pressure?
Emphysema?
Do you smoke or vape?
Do you use chewing tobacco?
Blood transfusion?
Chest pain or angina?
Heart attack?
Irregular heart beat?
Cardiac pacemaker?
Heart surgery?
Pneumonia, bronchitis, chronic cough?
Asthma?
Hay fever/sinus problems?
Snoring?
Sleep apnea or CPAP?
Difficulty breathing or other lung trouble?
Tuberculosis?
Kidney trouble?
High cholesterol?
Are you on dialysis?
Swollen ankles or arthritis or joint disease?
Osteoporosis or osteopenia?
Osteonecrosis?
Stomach ulcer or acid reflux?
COVID-19?
Contagious diseases?
Sexually transmitted diseases?
Problems with immune system?
Autoimmune disease?
Blood disorder such as anemia?
Bruise easily?
Bleeding tendency/abnormal bleeding?
Hepatitis, jaundice, or liver disease?
Infectious mononucleosis?
Gallbladder trouble?
Fainting spells?
Convulsions/epilepsy?
Stroke?
Thyroid trouble?
Diabetes?
Low blood sugar?
Delay in healing?
A tumor or growth?
Cancer/radiation therapy/chemotherapy?
Chronic fatigue/night sweats?
Are you on a diet?
A history of alcohol abuse?
A history of marijuana or other drug use?
Contact lenses?
Eye disease/glaucoma?
Mental health problems/anxiety/depression?
A removable dental appliance?
Pain or clicking of jaws when eating?
Is there a possibility of pregnancy?
Are you nursing?
Are you taking birth control pills?
Any kind of medication, drug, pills?
Blood thinners (Coumadin®, Plavix®, aspirin, vitamin E, ginkgo biloba, Aggrenox, Xarelto, Eliquis, fish oil?
Have you ever taken diet pills?
Are you taking, or have you ever taken bone density meds, RANKL inhibitors, or bisphosphonates such as Prolia®, Fosamax®, Boniva®, Actonel®, IV-Zometa®, Aredia®, Reclast®, Xgeva®, or Evista® in the past 12 years?
Any natural product, herbal supplement, or homeopathic remedy?
Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?
If you are under the care of a physician for pain management, or recovering from drug addiction, please select themedication you are currently taking
Local anesthetic (numbing medicine)?
Penicillin?
Other antibiotics?
Sulfa drugs?
Sodium pentothal/Valium®/other tranquilizers?
Aspirin?
Amoxicillin?
Codeine or other narcotics?
Latex?
Soy?
Eggs or yolk?
Sulfites?
If you are having surgery today, have you had anything to eat or drink in the last 6 hours?
Is there any condition concerning your health that the Doctor should be told about?
Is there a family history of
I certify that I have read and 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 doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
We make every effort to keep down the cost of your care. 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 insurance we will be glad to fill out the proper claim forms; 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 may pay fixed allowances for certain procedures, some may pay a percentage, and others may pay a percentage of that charge. The 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.
It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance company after 60 days. You will be responsible for all collection costs, attorney’s fees, and court costs. We will not submit any claims to medical insurance. In the instance that we may need to use an outside lab/facility for services rendered (i.e., lab or hospital), we ask that you please provide your medical insurance information, so that we may pass it along to these facilities to expedite processing of claims on your behalf. Any outside lab/facility used may incur separate fees, and will be billed separately from our offices.
I authorize my surgeon and his/her designated 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 a 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.
I permit messages to be left on my phone and/or mobile phone concerning my appointment.
I permit the office to communicate with me via text message on my cell phone.
I agree that the practice may communicate with me at the following address(es):
I consent to receive calls and text messages related to my protected healthcare and other services at the phone number(s) above, including my wireless number provided. I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system.
Do we have your permission to:
Send a recall appointment reminder to your home
Leave appointment, billing, or dental information on your answering machine/voicemail/email/text