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North Iowa Oral Surgery & Dental Implant Center

Mason City
1530 S Monroe Ave
Mason City, IA 50401

(641) 424-1656

Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM

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Document Signers
    • 1 Patient

Patient Information



Have you ever been a patient of our practice

Person Legally Responsible for the Account

Who will be responsible for the account?

Insurance Information

Subscriber Status

Primary Dental Subscriber Gender

Primary Medical Subscriber Gender

Secondary Dental Subscriber Gender

Secondary Medical Subscriber Gender

Financial Agreement

Payment Options

Payment in Full

Check here if you would like preauthorization or a pretreatment estimate of coverage from your insurance

Health History

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?

Are you allergic or have you had a reaction to any of the following?

Local anesthetics

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

Sinus Trouble


Stomach Ulcer or Frequent Heartburn

Liver Trouble (Hepatitis, Jaundice, or Liver Disease)

Kidney Trouble


Thyroid Problems

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?

Women Only

Are you pregnant or trying to become pregnant?

Are you nursing (breastfeeding)?

Are you taking birth control pills?

Acknowledgement of Receipt of Notice of Privacy Practices

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.)

Spouse only

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)