Step 1 of 6 16% Todays date General Patient InformationPatient first namePatient middle initialPatient last nameSalutation:MrMrsMsDrSexMaleFemaleBirth date AgeSocial security numberEmail address AddressAptCityStatePennsylvaniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipHome phone numberCell phone numberHave you ever been a patient of our practice?YesNoReferred byHas a family member ever been a patient of our practice?YesNoDentistOrthodontistMedical doctorDrivers license numberNearest relative not living with youPhone number of nearest relative not living with youEmployer of the patientBusiness phone numberPayment typeCashCheckCredit cardIn case of emergency please contact:Phone number of emergency contactEmergency contacts relationship to patient PERSON RESPONSIBLE FOR THE ACCOUNT:Person financially responsible for the accountSelf or patientOtherThe person responsible for the account:SpouseFatherMotherOtherIf other what is the relation?Name of person responsible for the accountSocial security number of the person resonsible for the accountBirth date of the person responsible for the account Age of the person responsible for the accountHome phone number of the person responsible for the accountCell phone number of the person responsible for the accountEmail address of the person responsible for the account Address of the person responsible for the accountApartment of the person responsible for the accountCity of the person responsible for the accountState of the person responsible for the accountPennsylvaniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of the person responsible for the accountDrivers license number of the person responsible for the accountEmployer of the person responsible for the accountBusiness phone number of the person responsible for the account SPOUSE OR OTHER GUARANTOR INFORMATION:Name of spouse or other guarantorGuarantors relationship to patientSocial security number of guarantorBirth date of guarantor Address of guarantorApartment of guarantorCity of guarantorState of guarantorPennsylvaniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of guarantorPhone number of guarantorEmployer of guarantorBusiness phone number of guarantor INSURANCE INFORMATION:Student status:Full-timePart-timeNot a studentName and address of schoolMarital status:MarriedDivorcedWidowSingleLegally seperatedEmployment status:Full-timePart-timeRetiredNot employedDo you belong to a PPO or HMO?YesNo Primary Dental Insurance CompanyEmployer of primary dental insuredBusiness address of primary dental insuredBusiness phone number of primary dental insuredPlan of primary dental insuredName of primary dental insurance companyID number of primary dental insuranceAddress of primary dental insurance companyPhone number of primary dental insurance companyGroup name of primary dental insuranceGroup number of primary dental insurancePrimary dental insured partyRelation of primary dental insured to patientDate of birth of primary dental insured Sex of primary dental insuredMaleFemaleSocial security number of primary dental insuredPhone number of primary dental insuredAddress of primary dental insured Primary Medical Insurance CompanyEmployer of primary medical insuredBusiness address of primary medical insuredBusiness phone number of primary medical insuredPlan of primary medical insuredName of primary medical insurance companyID number of primary medical insuranceAddress of primary medical insurance companyPhone number of primary medical insurance companyGroup name of primary medical insuranceGroup number of primary medical insurancePrimary medical insured partyRelation of primary medical insured to patientDate of birth of primary medical insured Sex of primary medical insuredMaleFemaleSocial security number of primary medical insuredPhone number of primary medical insuredAddress of primary medical insured Secondary Dental Insurance CompanyEmployer of secondary dental insuredBusiness address of secondary dental insuredBusiness phone number of secondary dental insuredPlan of secondary dental insuredName of secondary dental insurance companyID number of secondary dental insuranceAddress of secondary dental insurance companyPhone number of secondary dental insurance companyGroup name of secondary dental insurance companyGroup number of secondary dental insuranceSecondary dental insured partyRelation of secondary dental insured to patientDate of birth of secondary dental insured Sex of secondary dental insuredMaleFemaleSocial security number of secondary dental insurance companyPhone number of secondary dental insuredAddress of secondary dental insured Secondary Medical Insurance CompanyEmployer of secondary medical insuredBusiness address of secondary medical insuredBusiness phone number of secondary medical insuredPlan of secondary medical insuredName of secondary medical insurance companyID number of secondary medical insurance companyAddress of secondary medical insurance companyPhone number of secondary medical insurance companyGroup name of secondary medical insurance companyGroup number of secondary medical insuranceSecondary medical insured partyRelation of secondary medical insured to patientDate of birth of secondary medical insured Sex of secondary medical insuredMaleFemaleSocial security number of secondary medical insuredPhone number of secondary medical insuredAddress of secondary medical insured Health History To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have or medications 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. ALLERGIES: Are you allergic to or have you had a reaction to:Local anesthetic or numbing medication?YesNoPenicillin or other antibiotics?YesNoSulfa drugs?YesNoSodium pentothal or valium or other tranquilizers?YesNoAspirin?YesNoAmoxicillin?YesNoCodeine or other narcotics?YesNoLatex?YesNoSoy?YesNoEggs or egg yolk?YesNoSulfites?YesNoPlease list any other known allergies: MEDICATIONS: Are you now taking:Any kind of medication or drug or pills?YesNoBlood thinners such as Coumadin or Plavix or Aspirin or Vitamin E or ginko biloba or Aggrenox or Pradaxa or fish oil?YesNoDiet pills now or ever?YesNoBone density medications or bisphosphonates such as Fosamax or Boniva or Actonel or Aredia or Reclast or have you taken any of these in the last 12 years?YesNoAny natural product or herbal supplement or homeopathic remedy?YesNoPlease list any medications you are currently taking including dosage and frequency:Tranquilizers or sleeping pills or antidepressants or narcotics on a regular basis?YesNoIf so please list: Medical History (cont)Reason for todays office visitHeightWeightAre you in good health?YesNoHave there been any changes in your general health in the past year?YesNoAre you under the care of a physician?YesNoDate of last visit If so what are you being treated for?Have you had an illness or operation or been hospitalized in the past 5 years?YesNoIf so describeDo you have unhealed or recurrent injuries or inflamed areas or growths or sore spots in or around your mouth?YesNoIf so describe whereDo you have a prosthetic joint or implants?YesNoIf yes describe whereHave you had a heart valve replacement or vascular graft?YesNoHave you ever had general anesthesia?YesNoHave you or a family member had any unusual or serious reactions to general anesthesia?YesNoHas a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?YesNoAre you currently on a diet?YesNoDo you wear contact lenses?YesNoDo you have or have you had a removable dental appliance?YesNo Medical History (cont)Have you had or do you currently have:Rheumatic fever?YesNoDamaged heart valves or mitral valve prolapse?YesNoHeart murmur?YesNoHigh blood pressure?YesNoLow blood pressure?YesNoChest pain or angina?YesNoHeart attack or heart attacks?YesNoIrregular heart beat?YesNoCardiac pacemaker?YesNoHeart surgery?YesNoPneumonia or bronchitis or chronic cough?YesNoAsthma?YesNoHay fever or sinus problems?YesNoSnoring or sleep apnea?YesNoDifficult breathing or lung trouble?YesNoTuberculosis?YesNoEmphysema?YesNoBlood transfusion?YesNoBlood disorder such as anemia?YesNoBruise easily?YesNoBleeding tendency or abnormal bleeding?YesNoHepatitis or jaundice or liver disease?YesNoInfectious mononucleosis?YesNoGallbladder trouble?YesNoFainting spells?YesNoConvulsions and epilepsy?YesNoStroke?YesNoThyroid trouble?YesNoDiabetes?YesNoLow blood sugar?YesNoKidney trouble?YesNoHigh cholesterol?YesNoOn dialysis?YesNoSwollen ankles or arthritis or joint disease?YesNoOsteoporosis or osteopenia?YesNoOsteonecrosis?YesNoStomach ulcers or acid reflux?YesNoContagious diseases?YesNoSexually transmitted diseases?YesNoProblems with immune system possibly from medication or surgery?YesNoDelay in healing?YesNoTumor or growth?YesNoCancer or radiation therapy or chemotherapy?YesNoChronic fatigue or night sweats?YesNoEye disease or glaucoma?YesNoPain or clicking in jaws?YesNoHistory of alcohol abuse?YesNoHistory of drug abuse?YesNoMental health problems or anxiety or depression?YesNoSmoke or chew tobacco?YesNoNumber of packs a day? Health History (cont)If you are having surgery today have you had anything to eat or drink in the last six hours?YesNoWho is driving you home?Is there any condition concerning your health that the doctor should be told about?YesNoIf yes please describe the condition:Do you wish to speak to the doctor privately about anything?YesNoDate of injury Insurance company handling the claimClaim numberName of attorney or adjustorPhone number of attorney or adjustorIs there a possibility of pregnancy?YesNoIf yes what is the expected delivery date? Are you nursing?YesNoAre you taking birth control pills?YesNoI certify that I have read and 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 doctor 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 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 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, co-insurance, or any other balance not paid by your insurance company. You will be responsible for all collection costs, attorney’s fees, and court costs. This 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 authorize my surgeon and his/her designated staff to perform an oral and maxillofacial examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. 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.