CONESTOGA ORAL SURGERY
Online Registration Forms
NAME
*
First Name
Middle Name
Last Name
DATE OF BIRTH
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
AGE
*
SEX
*
Male
Female
HOME ADDRESS
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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Colorado
Connecticut
Delaware
District of Columbia
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
SOCIAL SECURITY NUMBER
*
*
Rows
PLEASE LIST
HOME PHONE NUMBER
MOBILE PHONE NUMBER
WORK PHONE NUMBER
EMAIL
*
EMPLOYER/DEPARTMENT
EMERGENCY CONTACT
*
Please include name and phone number
How did you hear about us?
*
E.g. referred by doctor, friend/family member, internet search, insurance, etc.
*
Rows
NAME
MEDICAL PHYSICIAN
GENERAL DENTIST
ORTHODONTIST
GUARANTOR INFORMATION (Please complete if person responsible for insurance or payment is someone other than the patient)
First Name
Middle Name
Last Name
RELATIONSHIP TO PATIENT
HOME ADDRESS
Street Address
City
State
Zip Code
DATE OF BIRTH
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
SOCIAL SECURITY NUMBER
Rows
PLEASE LIST
HOME PHONE NUMBER
MOBILE PHONE NUMBER
WORK PHONE NUMBER
PRIMARY INSURANCE INFORMATION
Rows
MEDICAL INSURANCE
DENTAL INSURANCE
Company Name
Insurance Address
Insured Party
Insured DOB
Insured SSN #
Relation to Patient
Insured ID #
Group #
Employer Name
SECONDARY INSURANCE INFORMATION
Rows
MEDICAL INSURANCE
DENTAL INSURANCE
Company Name
Insurance Address
Insured Party
Insured DOB
Insured SSN #
Relation to Patient
Insured ID #
Group #
Employer Name
To expedite your check-in process, please upload images of the front and back of your insurance cards and drivers license/photo identification.
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HEALTH HISTORY
Although Oral and Maxillofacial Surgeons primarily treat the area in and around your mouth, it is important that we have a clear understanding of your current/previous state of health. Any health problems you have could affect the care you are receiving. Please carefully complete read and complete the fields below. This information allows your surgeon to provide the best care possible to you or your family member. This information will be reviewed with you upon your arrival to our office and all responses are kept CONDFIDENTIAL and are for our records only.
HEIGHT
*
WEIGHT
*
CHIEF DENTAL COMPLAINT:
*
*
Rows
YES
NO
Please list any additional details
Are you in good health?
Have there been any changes in
your general health in the last year?
Are you currently under the care of
a physician? If so, for what are you
being treated?
Have you recently been hospitalized
for a serious illness?
DO YOU HAVE OR HAVE YOU EVER HAD:
*
Rows
YES
NO
Please list any additional details
Rheumatic Fever/Rheumatic Heart Disease
Heart Attack(s)
Heart Murmur
High Blood Pressure
Chest Pain/Angina
Irregular Heart Beat
Previous Heart Surgery
Cardiac Pacemaker
Artificial Heart Valves
Stroke(s)
Bronchitis/Emphysema
Asthma
Chronic Cough/Shortness of Breath
COPD
Pneumonia
Tuberculosis
Seizures
Fainting/Dizziness
Bleeding Disorder(s)
Anemia
Previous Blood Transfusion
Liver Disease (Jaundice, Hepatitis)
Kidney Disease
Diabetes - Please specify Type I or Type II
(Please list most recent HbA1C)
Thyroid Disease
Arthritis
Gastrointestinal Disease (Ulcers, Colitis)
Eye Disease/Glaucoma
Osteoporosis
Joint Replacements
Do you pre-medicate prior to dental procedures?
Radiation/Chemotherapy
Difficulty opening mouth/popping of TMJ
Grinding or Clenching Teeth
Sinus or Nasal Problems
Any disease, drug, or transplant operation that
has suppressed the immune system
HIV/AIDS
History of Eating Disorder
Sexually Transmitted Disease (Please List)
Psychiatric Disorders (Please List)
Rows
YES
NO
Please List Additional Details
Do you smoke (cigarettes, cigars, marijuana),
vape, or use chewing tobacco - How much per day?
Do you have a past history of alcohol or chemical
dependence?
Has anyone in your family had any problems associated
with anesthesia?
Please List ALL previous surgeries:
Please list ALL medications that you are currently taking including prescriptions medications, diet drugs, over-the-counter medications, herbal/holistic remedies, and vitamins:
ARE YOU OR HAVE YOU EVER USED ANY OF THE FOLLOWING:
*
Rows
YES
NO
Please List
ANTICOAGULANT MEDICATIONS
(Coumadin, Plavix, Eliquis, Pradaxa, Aspirin, etc)
STEROIDS (Cortisol, Prednisone, etc)
BISPHOSPHONATES for Osteoporosis, Multiple Myeloma,
or other cancers (Reclast, Zometa, Fosamax, Xgeva, Actonel,
Prolia, etc)
Have you ever been advised not to take a medication?
(If so, please list)
Please list ALL allergies and adverse reactions to any medications, latex, food products, or local anesthetics.
*
*If you have no allergies, please write NO KNOWN ALLERGIES in the space provided.
FOR WOMEN ONLY:
Rows
YES
NO
Are you pregnant, or is there a chance you could be pregnant?
Are you nursing?
Date of last period:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
CONESTOGA ORAL SURGERY - FINANCIAL POLICY and AGREEMENT
Please read the document below and then click the box below to confirm that you understand and agree with the listed policies
CONESTOGA ORAL SURGERY - NOTICE of PRIVACY PRACTICES
Please read the document below and then click the box below to confirm that you understand our HIPAA office policies
PATIENT RECORD OF DISCLOSURES
In general, the HIPAA privacy rule gives individuals the right to request a restriction on the uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.
I wish to be contacted in the following manner with the phone numbers that I have provided to Conestoga Oral Surgery (Please select the appropriate choice):
*
Please Select
OK to leave a voicemail with detailed information
Leave message with call back number only
OK to provide information to another person
*This information will be considered current & valid unless otherwise notified
The following individuals may be contacted to discuss my medical care if necessary:
Rows
Name
Relationship
Phone Number
Authorized Individual 1
Authorized Individual 2
Authorized Individual 3
I certify that I have read and understand the above information I have provided. I acknowledge that the questions to the inquiries set forth above have been answered to my satisfaction and are true and accurate. I will not hold my surgeon, or any other member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.
*
Signature of Patient/Guardian
Date of Submission of Online Registration
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
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