REGISTRATION & MEDICAL HISTORY FORM

Do you have DENTAL Insurance?*

YesNo
DENTAL INSURANCE:

Oral surgery procedures may be covered by dental insurance. Dr. Alman is NOT a perferred provider for any insurance plans. HMOs & Discount Plans do not have any out of network benefits.

If you have coverage has out-of-network benefits we will be pleased to assist by filing a claim on your behalf. We are filing for you to be reimbursed according to the out-of-network benefits available.
Member/Subscriber?*

SelfSpouseMotherFatherChildOther
Subscriber Information:*
DENTAL Insurance:*
Non-Participation:*
Please attach a copy of the DENTAL insurance card:

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GENERAL HEALTH:
Do you see a medical doctor for ANY reason other than routine care?*

YesNo
Has there been any changes to your general health in the last 2 years?*

YesNo
Past 2 years changes to general health.
Please describe any changes to your general health in the last 2 years.
Your Physician's Contact Information may be needed to contact them for medical clearance or medical manaagment. If you see multiple specialists please gather their information as well for later at the end of this form add each Name, Specialty, Telephone Number, Email, and Fax Number. We don't need the address but, the City, and State is appreciated.
Have you had an illness, operation, or been hospitalized in the past 5 years?*

YesNo
Illness, Operation, or Hospitalization Additional Information:*
Please describe the Illness, Operation, or Hospitalization including dates. You can attach any medical records later on this form.

ANTIBIOTICS - Premed:
Do you need to take antibiotics prior to dental surgery?*

YesNo
Are you on an antibiotic now?*

YesNo
Antibiotic Additional Information: *
Do you have any Prosthetic Joints?*

YesNo
Does your Physician require you to take an Antibiotic Prior to Dental Care?*

YesNo
Prosthetic Joint(s) Add'l Info.*
Please provide details on which Joints & How Long Ago (Year is Helpful).

Do you have Diabetes?*

Yes - Not on MedicationYes - On MedicationNo
Diabetes Information:
Diabetes Medications Including Insulin:

Have you had any Cancers or Tumors?*

YesNo
Cancer / Tumors Add'l Info.
Please provide details such as type of cancer/tumor, where, and surgical dates.
Are you currently on any medication for Cancers or Tumors?*

YesNo
Cancer or Tumor Medications: *

Do you have a disease, condition, or problem not listed previously?*

YesNo
Disease / Condition/ Not Previously Listed Add'l Info.*
Please explain. If you have a report or medical communication you can upload it later in this form.

Do you have plans to travel or fly soon?*

YesNo
Travel plans need to be considered when scheduling oral surgery procedures. Often we try to have patients nearby for a week or longer after a surgery in case there is a post operative concern. Please discuss this with our office when scheduling.
Travel Add'l Info.*
Some surgeries usually have a 1 week follow-up. This may be important with scheduling.;
Are you an Athlete?*

YesNo
Athletic activity may need to be avoided after oral surgery.

For some surgerical procedures raising the head blood pressure may cause bleeding or lose of a blood clot - we generally as for patients to avoid excercising, lifting weights, or even bending down for 48 hours.

Other sugical procedures may require refraining for an even longer period but, not typically so.

Some sports may involve the potential for head interaction/contact. Please let us know if you are involved in a sport that may fit this discription.
Athlete Add'l Info.*
Some sports need to be avoided for several days or weeks after surgery. This may need consideration.
Are you a Swimmer?*

YesNo
Swimming should be avoided for a minimum of 3 days after oral surgery. Dr. Alman would prefer 5 days. The concern is questionably clean water and open wounds. Please call our office if you have any questions.
Swimmer Add'l Info.*
Usually NO swimming for 3 days after surgery. This may need consideration.
Do you play a Wind Instrument or are a Singer?*

YesNo
Both wind instruments and singing involve using the muscles of the mouth.

Some procedures especially the removal of several wisdom teeth may cause stiffness and or muscle fatigue.

Dr. Alman generally asks patients to avoid both playing a wind instrument or singing for a week after surgery. Other sugical procedures may require refraining for an even longer period but, not typically so.

Please call our office if you have any questions.
Instruments / Singer Add'l Info.*
Wind instruments & singing involve the muscles of the mouth. This may need consideration.

General Practitioner (GP):
Heart / Circulatory Physician:
Blood Thinners / Anticoagulants Prescribing Physician (if not the Heart/Circulatory Physician):
Bone Density Prescribing Physician:
Diabetes Physician:
Cancer / Tumor Physician:
Respiratory Physician (or Allergist):
Other Physician:

Payment for the Services will be paid by: (AMEX is not available)*

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Financial Agreement:*

Health History:*
Overall Form Acknowledgment:*
Privacy:*
Please attach a recent photo or an ID of the patient:

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PHOTOS: As an option - You may also take photos of your ID, referral, and other information.

REFERRAL: This may have already been sent by your referring dentist:

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X-RAYS: Please attach any X-rays (Often they are sent electronically by the referring dentist):

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Signature: *

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RALPH W ALMAN JR DDS PA