Page 1 of 4

REGISTRATION

Dental and medical cards required in office at time of appointment

Today's Date

Patient First Name

Patient Last Name

Gender

Male

Female

Cell Phone

Home Phone

Email (for appointment confirmation only)

Birthdate

Age

Social Security Number

Mailing Address

Apartment Number

City

State

Zip

Have you ever been a patient of our practice?

Yes

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

Yes

Referred By First Name

Last Name

Orthodontist First Name

Last Name

Dentist First Name

Last Name

Medical Doctor First Name

Last Name

Emergency Contact First Name

Last Name

Emergency Contact Phone Number

Relation

Second Contact First Name

Last Name

Relation

Phone

Employer

Employed

Full-time

Part time

Retired

Not Employed

Marital Status

Married

Divorced

Widowed

Single

Legally Separated

Student

Full-time

Part time

Not

School Name

Page 2 of 4

PERSON RESPONSIBLE FOR ACCOUNT

Dental and medical cards required in office at time of appointment

(If self, skip this section)

Person Responsible for Account

Self

Spouse

Father

Mother

Other

Other Person Responsible

First Name

Last Name

Social Security Number

Date of Birth

Age

Mailing Address

Apt

City

State

Zip

Cell Phone Number

Home Phone Number

Employer

OTHER GUARANTOR INFORMATION:

(If different than above)

Last Name

First Name

Relation

Social Security Number

Date of Birth

Age

Mailing Address

Apt

City

State

Zip

Cell Phone

Home Phone

Employer

INSURANCE

Dental

Primary Insurance Company Name

Insurance Company Address

City

State

Zip

ID Number

Group

Policyholder First Name

Last Name

Relation

Date of Birth

Social Security Number

Employer

Gender

Male

Female

Address

City

State

Zip

Phone Number

Secondary Insurance Company Name

Insurance Company Address

City

State

Zip

ID Number

Group

Policyholder First Name

Last Name

Employer

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Address

City

State

Zip

Phone Number

Medical

Primary Insurance Company Name

Insurance Company Address

City

State

Zip

ID Number

Group

Policyholder First Name

Last Name

Employer

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Address

City

State

Zip

Phone Number

Secondary Medical Insurance Name

Insurance Company Address

City

State

Zip

ID Number

Group

Policyholder First Name

Last Name

Employer

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Address

City

State

Zip

Phone Number

Page 3 of 4

HEALTH HISTORY

Dental and medical cards required in office at time of appointment

Date

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the care that you will receive. Thank you for answering the following questions. Your answers are for our records only. All responses are kept confidential.

Reason for today's office visit?

Height

Weight

Are you under the care of a physician?

Yes

If so what are you being treated for

Date of last visit

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

Yes

MEDICAL HISTORY

Do you have or have you ever had any of the following?

No Past Medical History

Rheumatic Fever

Problems With Immune System

Difficult Breathing Other Lung Trouble

Damaged Heart Valves

Acid Reflux GERD

Delay in Healing

Damaged Heart Valves: Mitral Valve Prolapse

Ulcers Intestinal Ulcers

Heart Valve Replacement

History of Blood Transfusion

Heart Murmur

Anemia

History of Tumor or Growth

High Blood Pressure

Bruise Easily

Low Blood Pressure

Bleeding Tendency or Abnormal Bleeding

Cancer

Chest Pain Angina

Heart Attack

Chemotherapy

Gallbladder Disease

Radiation

Hypoglycemia Low Blood Sugar

Chronic Fatigue Night Sweats

Kidney Disease

Cardiac Pacemaker

Kidney Renal Dialysis

Congestive Heart Failure

Seizures Convulsions Epilepsy

Swollen Ankles

Fainting Spells

High Cholesterol Hyperlipidemia

Stroke TIA

Sinus Disease

Rheumatoid Arthritis

Hay Fever Seasonal Allergies

Osteoarthritis Joint Disease

Snoring

Osteoporosis Osteopenia

Sleep Apnea

Hormone Replacement Therapy

Sleep Apnea: CPAP Use

Osteonecrosis

Asthma

Tuberculosis

Contagious Diseases

Infectious Mononucleosis

Emphysema COPD

Sexually Transmitted Diseases

Pneumonia Bronchitis Chronic Cough

On a Diet

Anxiety or Depression

Bipolar

ADHD

Migraines

Fibromyalgia

Vertigo

Dementia

Alzheimers

Parkinsons

Pain or Clicking of Jaws When Eating

History of Alcohol Abuse

History of Drug Abuse

History of Marijuana

History of Tobacco Use

Coronary Artery Disease

Coronary Artery Disease: Cardiac Stent

Coronary Artery Disease: Bypass Graft

Irregular Heartbeat

Irregular Heartbeat: A-fib

Irregular Heartbeat: SVT

Irregular Heartbeat: PVC

Hepatitis

Hepatitis: Jaundice

Hepatitis: Liver Disease

Diabetes Mellitus

Diabetes Mellitus: Type 1

Diabetes Mellitus: Type 2

Thyroid Disease

Thyroid Disease: Hyperthyroid

Thyroid Disease: Hypothyroid

Eye Disease

Eye Disease: Glaucoma

Eye Disease: Cataracts

Eye Disease: Blind

Reason for Problems With Immune System

Indicate Type of History of Tumor or Growth

Indicate Type of Cancer

When did you have a heart attack?

Please list History of Drug Abuse

When did you have a Pneumonia, Bronchitis, or Chronic Cough?

How many packs of cigarettes do you smoke a day?

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

Yes

If so describe

Have you been hospitalized in the past?

Yes

Have you been hospitalized in the past? If so describe

Any past surgeries?

If yes please list below

Please list any past surgeries

Do you have a prosthetic joint/implant?

Yes

Do you have a prosthetic joint/implant? If so where

MEDICATIONS

Are you now taking or have you ever taken any of the following?

Not taking any medications

Blood Thinners

Any Natural Product Herbal Supplement or Homeopathic Remedy

Tranquilizers Sleeping Pills Antidepressants

Diet Pills

Blood thinners include, but are not limited to: (Coumadin®, Plavix®, Aspirin, Vitamin E, Gingko Biloba, Aggrenox®, Pradaxa®, Fish Oil)

Please list any medications you are currently taking:

Are you taking or have you ever taken the following bone density meds or bisphosphonates in the past 12 years?

Foxmax

Boniva

Actonel

IV Zometa

Aredia

Prolia

When have you taken biophosphates?

If you are having surgery today, have you had anything to eat or drink in the last eight hours?

Yes

Who is driving you home? Full Name

Relation

Phone

Expected due date

Note: Antibiotics may alter the effectiveness of birth control pills. Consult your physician or gynecologist for assistance regarding other methods of birth control.

Pharmacy Name

Pharmacy Address

Page 4 of 4

Allergies

Dental and medical cards required in office at time of appointment

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

No Known Drug Allergies

Latex

Propofol Sodium Pentothal Valium or Other Tranquilizers

Local Anesthetic

Codeine Vicodin Norco or other Narcotics

Sulfa Drugs

Other Antibiotics

Other Medications list

Aspirin

Nuts

Food Allergies list

Allergy to Codeine or Vicodin? Please list

Propofol Sodium Pentothal Valium or Other Tranquilizers? Please list

Food Allergies list

Please list all other medications

Please list any additional allergies

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

Yes

Accident Related

Is this visit related to an accident?

Yes

If yes, what type of accident?

Work Related

Automobile

Other

Insurance company handling the claim

Date of injury

Claim number

Name of attorney or adjustor

Phone number

FEES AND 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 you must provide complete and correct information. 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 pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney fees, and court costs.

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 permit messages to be left on my phone concerning my appointment.

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.

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.

Patient Name

Date

disregard this