Skip to form

Utah Surgical Arts

Address:
South Jordan
11748 S 3600 W, #1
South Jordan, UT 84095

Other Locations:
Provo
3610 North University Avenue, Suite 150
Provo, UT 84604

Payson
1107 South Highway 198
Payson, UT 84651

Phone:
(801) 938-3412 - South Jordan
(801) 356-2226 - Provo
(801) 356-2226 - Payson


Hours:
Mon–Fri: 8:00 AM–5:00 PM

Contact Us

Document Signers
    • 1 Patient

Page 1 of 3


General Patient Information

Gender

Marital Status


(If patient is over 18 y/o and a full time student):


Emergency Contact Information


Page 2 of 3

Responsible Party Information (Financial)

Gender


Insurance Information

Primary Dental Insurance

Primary Medical Insurance

Secondary Dental Insurance

Secondary Medical Insurance


Page 3 of 3

Medical History

*Please answer all questions correctly and completely. Your answers are for our records only and will be kept confidential.

Please list all current medications, including diet pills, non-prescription, vitamins, homeopathic or natual remedies

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

Allergies

Are you now under the care of a physician

Do you have any of the following diseases of problems?

Have you taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis

Have you had any serious illness, operation, or hospitalization in the last 5 years

Do you wish to talk with the doctor about anything privately

Are you taking any blood thinners (Coumadin®, Plavix®, aspirin, vitamin E, ginkgo biloba)

Have you had any serious problems associated with any previous dental treatment

Are you wearing a removable dental appliance

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in/around mouth

Have you had an artificial joint replacement (knee, hip, shoulder, etc.)

Have you taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast®, Fosamax®, Boniva®, Actonel®, Boniva®, Aredia®, or Zometa®)

Are you wearing contact lenses


Women Only

Are you pregnant or trying to become pregnant

Do you have problems associated with your menstrual period

Are you nursing

Are you taking birth control pills


If this visit is related to an accident


If you are having surgery today

Ingested Food or Drink