1530 S Monroe Ave
Mason City, IA 50401
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM
Have you ever been a patient of our practice
Who will be responsible for the account?
Primary Dental Subscriber Gender
Primary Medical Subscriber Gender
Secondary Dental Subscriber Gender
Secondary Medical Subscriber Gender
Payment in Full
Check here if you would like preauthorization or a pretreatment estimate of coverage from your insurance
Are you under the care of a physician?
Are you taking any medications?
Do you take or have you ever taken or been given any of the following medications?
Penicillin or antibiotics
Barbiturates or sleeping pills
Aspirin or ibuprofen
Codeine or other narcotics
Latex or rubber products
Have you ever had any surgery, serious illness, or hospitalization in the past?
Have you or any family members had any serious reactions to IV sedation or general anesthesia?
Do you have or have you had any of the following diseases or problems?
Damaged Heart Valves, Artificial Valves, or Heart Murmur
History of Snoring, Sleep Apnea, or Use of CPAP
Rheumatic Heart Disease
Heart Attack, Heart Surgery, or Irregular Heartbeat
High Blood Pressure
Asthma, Hay Fever, or Allergies
Emphysema, Bronchitis, Etc
Stomach Ulcer or Frequent Heartburn
Liver Trouble (Hepatitis, Jaundice, or Liver Disease)
Seizures (Epilepsy), Stroke, or Neurological Disorder
Any Disease, Drug, or Transplant Operation that has Suppressed your Immune System
Are you taking any blood thinners?
Arthritis or Painful, Swollen Joints including Jaw Joint (TMJ)
Have you taken any steroid medications in the past two years?
Do you have any blood disorders?
Abnormally prologned bleeding
Have you ever required a blood transfusion?
Do you have any artificial joints?
Have you ever been treated for glaucoma?
Have you ever had treatment for a tumor or cancer?
Radiation therapy involving the mouth, face, or neck
Do you smoke or have your ever smoked?
Have you ever been treated for alcohol or other substance abuse?
Have you ever or you currently use any recreational/illicit drugs?
Have you had a cold, flu, sore throat, sinus infection, or other respiratory tract infection in the past week?
Do you have any other concerns or diseases you think the doctor should know about?
Do you wish to talk to the doctor privately about anything?
Are you pregnant or trying to become pregnant?
Are you nursing (breastfeeding)?
Are you taking birth control pills?
Additional disclosure authorization
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of North Iowa Oral Surgery & Dental Implant Center. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
North Iowa Oral Surgery & Dental Implant Center reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected healthcare information to the person(s) identified below. (I understand that the default answer is NO. Without indicating YES in answer to each individual question, personal protected healthcare information [PHI] cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Any member of my immediate family
Any member of my extended family
Other Disclosure Party
Upload a copy of your insurance card (front and back)