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Greater Columbus Oral Surgery & Dental Implants

Address:
Grove City
3824 Hoover Road
Grove City, OH 43123


Phone:
(614) 875-1611

Hours:
Mon–Thu: 7:30 AM–4:00 PM
Fri: 7:30 AM–3:30 PM

Contact Us

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    • 1 Patient

Patient Information

Salutation

Sex

Have you ever been a patient of our practice?

Payment

Person Responsible For The Account

Person responsible for your account

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Spouse or Other Guarantor Information

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Insurance Information

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Health History

To our patients: Although oral surgeons primarily treat the area 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 be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Are you in good health?

Have there been any changes to your general health in the last five years?

Are you under the care of a physician?

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Have you had any illness, operation, or been hospitalized in the past five years?

Do you have unhealed/recurrent injuries of 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 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?

Have you had or do you currently have any of the following?

Rheumatic Fever

Damaged Heart Valves/Mitral Vale Prolapse

Heart Murmur

High Blood Pressure

Low Blood Pressure

Chest Pain/Angina

Heart Attack(s)

Irregular Heart Beat

Cardiac Pacemaker

Heart Surgery

Pneumonia, Bronchitis, Chronic Cough

Asthma

Hay Fever/Sinus Problems

Snoring/Sleep Apnea

Difficulty Breathing/Lung Trouble

Tubercolosis

Emphysema

Do you smoke?

Blood Transfusion

Blood disorders 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

Kidney Trouble

Are you on dialysis?

Swollen ankles, arthritis or joint disease

Osteoporosis/Osteopenia

Osteonecrosis

Stomach Ulcers

Contagious Diseases

Sexually Transmitted Diseases

Immunosuppression

Immune System Problems

Delay In Healing

Tumor or Growth

Cancer, Radiation Therapy, Chemotherapy

Chronic Fatigue/Night Sweats

History of Drug Abuse

History of Alcohol Abuse

Contact Lenses

Eye Disease/Glaucoma

Mental Health Problems

Removable Dental Appliance

Pain and Jaw Clicking

Malignant Hyperthermia

Do you use chewing tobacco?

Are you on a diet?

Is there a possibility of pregnancy?

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Are you nursing?

Are you taking birth control pills?

Women, please note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Medication

Are you now taking any of the following?

Any kind of medication, drug, pills

Blood Thinners

Diet Pills

Any natural product, herbal supplement, or homeopathic remedy

Any bone density medications/biphosphonates

Tranquilizers, Narcotics, Etc

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?

Is there a family history of:

Family History: Cancer

Family History: Diabetes

Family History: Heart Disease

Family History: Anesthetic Problems

Allergies

Local Anesthetic

Penicillin

Other Antibiotics

Sulfa Drugs

Sodium Pentothal, Valium, or other tranquilizers

Aspirin

Codeine or Other Narcotics

Other Medications

Latex Allergy

Soy Allergy

Eggs or Yolk Allergies

Sulfites

In case of emergency, contact

Authorization To Release Information

I request and authorize Greater Columbus Oral Surgery & Dental Implants to release healthcare information, including pre/postop surgical instructions, questions, concerns, and appointments, prescription refills and pick-ups, and financial and billing information, to the following:

Final Notes

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 surgeon, 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 oral surgical 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 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's fees, and court costs.


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.

Authorization

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.