OMFS Inc Medical History Form and Consent

Omfs Inc. Medical History Form
Full Name (As Printed on Health Card) *

First NameMiddle NameLast Name
Street/Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
DOB (DD/MM/YY)*
Health Card #*
Health Card expiry date (MM/YY)*
Next of Kin*
Next of Kin Phone Number*

Area CodePhone Number
Dental Insurance Provider (Company Name - If Applicable)*
Insurance ID/Certificate # : *
Insurance Policy Number*
Insurance Plan Member's Name (Might be a Spouse or Parent) : *
Insurance Plan Member's DOB: (DD/MM/YY)*
Do you have, or have you ever had the following (please check all that apply):*

I am not aware of any health concernsAsthma, emphysema, or bronchitisJaw joint problems ("TMD" or "TMJ")Rheumatic FeverScarlet FeverArthritisDisease of eyes, ears, nose, or throatAbnormal bleedingVenereal diseaseIndigestion (acid reflux/heartburn?), hernias, ulcersInfectious diseases (e.g. Hepatitis, HIV/AIDS, TB)A bacteria resistant to antibiotics, like MRSA or VRBAnemiaCancerRadiation/chemotherapyCardiac disease, angina, or chest painHeart surgery, condition, or murmurShortness of breath after climbing one flight of stairsHigh blood pressureLow blood pressureDiabetes Type 1Diabetes Type 2Thyroid issuesAnxiety, depression, or mental illnessEpilepsy or seizuresStroke or mini stroke ("TIA")Kidney or urinary problemsIf you are female, is there a chance you could be pregnantIf you are female, are you currently nursing or breastfeedingDo you have sleep apneaIf you have a sleep partner, have they told you that you snore loudly, or do you often feel poorly rested throughout the day even after a full night of sleepOther
Is there anything else we should know about your health? Please specify:*
Please list all medications you currently take (prescribed and non-prescribed) including dosage. If more than 3 meds, please list your name and location of pharmacy and we will contact them.*
Do you smoke/chew tobacco? How much?*
Do you use THC/ CBD? How much?*
Use of substances prior to appointment:*

By checking this box I certify that I will not consume cannabis or alcohol, or use recreational drugs for 12 hours before my scheduled appointment time.
If you have any allergies to medications, please specify:*
Have you ever had an adverse reaction to (check any that apply):

General anestheticLocal anestheticI.V. sedation
By typing my name in the box below, I certify that I have read and I understand the questions above and have completed this form to the best of my knowlege. I will not hold my surgeon, or any other member of his staff, responsible for any errors or omissions I have made in the completion of this form. Further, I consent to the performing of the oral surgery procedures agreed to be necessary or advisable for myself; or for someone else if I am their legal guardian/substitute decision maker. Also, I will assume responsibility for the fees associated with the procedures.
Patient Name*

First NameLast Name
Legal guardian name/Substitute decision maker's name (if patient is under 19 or unable to provide consent)

First NameLast Name
Omfs Inc. Privacy and Consent Acknowledgment: Omfs Inc. operates under provincial guidelines set by the Personal Health Information Act (PHIA), which may be reviewed here: https://novascotia.ca/dhw/phia/ . Having read and understood my rights under the PHIA, I hereby consent to the collection, use, and disclosure of my personal information as presented in the statement, subject to the restriction identified below.*

No restrictions: Any collected information may be shared with my insurance company or other health professionals who are directly involved with my dental or medical care.Restricted access: My personal information shall NOT be provided to the following individuals or organizations (specified below)Restricted information: My personal information disclosed shall NOT include the folowing personal information (specified below)
If you selected to for your health information to have restricted access or restricted information, please specify here:
Please review the following point carefully:*

I verify the information I have provided on this form is truthful and accurate. By typing my name in the box below, I knowingly and willingly consent to have treatment.
Name*

First NameLast Name
Should be Empty:

Omfs Inc. Medical History Form