Page 1 of 5

General Patient Information

Today's Date

Title

Mr.

Mrs.

Ms.

Dr.

First Name

M.I.

Last Name

Gender

Birth Date

Age

Social Security Number

Address

Apartment Number

City

State

Zip

Home Phone Number

Cell Phone Number

Have you ever been a patient of our practice?

Yes

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

Yes

Referred By

Dentist

Orthodontist

Medical Doctor

Drivers License Number

Nearest relative not living with you

Phone Number

Employer

Business Phone Number

Payment Type

Cash

Check

Credit Card

In case of emergency, please contact

Phone Number

Relation

Page 2 of 5

PERSON RESPONSIBLE FOR ACCOUNT

If self, skip this section

Spouse

Father

Mother

Other

Full Name

Social Security Number

Birth Date

Age

Home Phone Number

Cell Phone Number

Address

Apartment Number

City

State

Zip

Drivers License Number

Employer

Business Phone Number

SPOUSE OR OTHER GUARANTOR INFORMATION

If self, skip this section

Full Name

Relation

Social Security Number

Birth Date

Address

Apartment Number

City

State

Zip

Phone Number

Employer

Business Phone Number

Page 3 of 5

INSURANCE INFORMATION

Student

Full Time

Park Time

Not a Student

School Name and Address

Marital Status

Married

Divorced

Widow

Single

Legally Separated

Employed

Full Time

Part Time

Retired

Not Employed

Do you belong to a PPO or HMO?

Yes

Primary Dental Insurance Company

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

ID Number

Insurance Company Address

Phone Number

Group Name

Group Number

Insured Party

Relationship

Date of Birth

Gender

Social Security Number

Phone Number

Insured Address

Secondary Dental Insurance Company

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

ID Number

Insurance Company Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Gender

Social Security Number

Phone Number

Insured Address

Primary Medical Insurance Company

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

ID Number

Insurance Company Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Gender

Social Security Number

Phone Number

Insured Address

Secondary Medical Insurance Company

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

ID Number

Insurance Company Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Gender

Social Security Number

Phone Number

Insured Address

Page 4 of 5

Health History

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. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

ALLERGIES

Are you allergic to or have you had a reaction to:

Local Anesthetic (Numbing Meds)

Penicillin or Other Antibiotics

Sulfa Drugs

Sodium Pentothal Valium or Other Tranquilizers

Aspirin

Amoxicillin

Codeine or Other Narcotics

Latex

Soy

Eggs or Yolk

Sulfites

Please list any other known allergies:

MEDICATIONS

Are you now taking

Any kind of medication drug pills

Blood thinners Coumadin Plavix Aspirin Vitamin E Ginko Biloba Aggrenox Pradaxa Fish Oil

Diet pills (Have you ever taken?)

Bone density medications/bisphosphonates such as Fosamax Boniva Actonel Aredia or Reclast (Have you taken in the past 12 years?)

Tranquilizers sleeping pills anti-depressants and/or narcotics on a regular basis

Any natural product herbal supplement or homeopathic remedy

If so, please list:

Please list any medications you are currently taking (including dosage and frequency):

Reason for todays office visit:

Height

Weight

Are you in good health?

Yes

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

Yes

Are you under the care of a physician?

Yes

Date of last visit

If so, what are you being treated for?

Have you had an illness, operation, or been hospitalized in the past 5 years?

Yes

If so, describe

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around your mouth?

Yes

If so, describe where

Do you have a prosthetic joint/implants?

Yes

If so, describe where

Have you had a heart valve replacement or vascular graft?

Yes

Have you ever had general anesthesia?

Yes

Have you or a family member had any unusual or serious reactions to general anesthesia?

Yes

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes

Are you currently on a diet?

Yes

Do you wear contact lenses?

Yes

Do you have or have you had a removable dental appliance?

Yes

Have you had or do you currently have

Rheumatic Fever

Damaged Heart Valves or Mitral Valve Prolapse

Heart Murmur

High Blood Pressure

Low Blood Pressure

Chest Pain/Angina

Heart Attack(s)

Irregular Heart Beat

Cardiac Pacemaker

Heart Surgery

Pneumonia Bronchitis or Chronic Cough

Asthma

Hay Fever/Sinus Problems

Snoring/Sleep Apnea

Difficult Breathing/Lung Trouble

Tuberculosis

Emphysema

Blood Transfusion

Blood Disorder (e.g. 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

Kidney Trouble

High Cholesterol

On Dialysis

Swollen Ankles/Arthritis/Joint Disease

Osteoporosis/Osteopenia

Osteonecrosis

Stomach Ulcers/Acid Reflux

Contagious Diseases

Sexually Transmitted Diseases

Problems with Immune System (possibly from medication or surgery)

Delay in Healing

Tumor or Growth

Cancer/Radiation Therapy/Chemotherapy

Chronic Fatigue/Night Sweats

Eye Disease/Glaucoma

Pain or Clicking in Jaws

History of Alcohol Abuse

History of Drug Abuse

Mental Health Problems/Anxiety/Depression

Smoke or Chew Tobacco

Number of packs smoked a day:

Page 5 of 5

Health History Continued

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Yes

Who is driving you home?

Is there any condition concerning your health that the doctor should be told about?

Yes

If yes, describe

Do you wish to speak to the doctor privately about anything?

Yes

INSURANCE CLAIM INFORMATION

Date of injury

Insurance company handling the claim

Claim Number

Name of attorney or adjustor

Phone Number

WOMEN ONLY

Is there a possibility of pregnancy?

Yes

If yes, expected delivery date?

Are you nursing?

Yes

Are you taking birth control pills?

Yes

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 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.

FEES & PAYMENTS: We make every effort to keep down the cost of your care. You can help by paying upon 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 on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and not a substitute for payment. Some companies pay fixed allowances 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 not paid by your insurance company. You will be responsible for all collection costs, attorney’s fees, and court costs.

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.

AUTHORIZATION: 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 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.

Full Name

disregard this

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