3824 Hoover Road
Grove City, OH 43123
Mon–Thu: 7:30 AM–4:00 PM
Fri: 7:30 AM–3:30 PM
Have you ever been a patient of our practice?
Person responsible for your account
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?
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?
Damaged Heart Valves/Mitral Vale Prolapse
High Blood Pressure
Low Blood Pressure
Irregular Heart Beat
Pneumonia, Bronchitis, Chronic Cough
Hay Fever/Sinus Problems
Difficulty Breathing/Lung Trouble
Do you smoke?
Blood disorders such as Anemia
Bleeding Tendency/Abnormal Bleeding
Hepatitis, Jaundice, or Liver Disease
Low Blood Sugar
Are you on dialysis?
Swollen ankles, arthritis or joint disease
Sexually Transmitted Diseases
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
Mental Health Problems
Removable Dental Appliance
Pain and Jaw Clicking
Do you use chewing tobacco?
Are you on a diet?
Is there a possibility of pregnancy?
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.
Are you now taking any of the following?
Any kind of medication, drug, 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?
Family History: Cancer
Family History: Diabetes
Family History: Heart Disease
Family History: Anesthetic Problems
Sodium Pentothal, Valium, or other tranquilizers
Codeine or Other Narcotics
Eggs or Yolk Allergies
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:
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.
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.
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.