1903 E Fir Ave
Fresno, CA 93720
(559) 226-2722 – Fresno
(559) 472-4050 – Clovis
(559) 480-3002 – Reedley
(559) 673-8337 – Madera
Mon–Thu: 8:00 AM–5:00 PM
Fri: 7:00 AM–4:00 PM
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Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?
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(If self, skip this section)
Person Responsible for Account
(If different than above)
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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.
Are you under the care of a physician?
Have there been any changes in your general health in the past year?
Do you have or have you ever had any of the following?
Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around your mouth?
Have you been hospitalized in the past?
Any past surgeries?
Do you have a prosthetic joint/implant?
Other Medical Problems
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have a removable dental appliance?
Do you wear contact lenses?
Do you have a family history of the following?
Is there any condition concerning your health that the doctor should be told about?
Do you wish to speak to the doctor privately about anything?
Are you now taking or have you ever taken any of the following?
Are you taking or have you ever taken the following bone density meds or bisphosphonates in the past 12 years?
If you are having surgery today, have you had anything to eat or drink in the last eight hours?
Note: Antibiotics may alter the effectiveness of birth control pills. Consult your physician or gynecologist for assistance regarding other methods of birth control.
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Are you allergic to or have you had a reaction to:
Have you or has a family member had any unusual or serious reactions to general anesthesia?
Is this visit related to an accident?
If yes, what type of accident?
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.
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.