Medical Insurance Information
General Insurance Information
Employed
Full Time
Part Time
Retired
Not
Do you belong to a PPO or HMO?
Yes
No
Marital Status
Married
Divorced
Widow
Single
Legally Separated
Are you a student?
Part Time
Full Time
No
Name
*
Prefix
First Name
Last Name
Gender
*
Male
Female
Age
*
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
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1991
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Phone Number (Mobile)
-
Area Code
Phone Number
Primary Dental Insurance Information
Employer / Business
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
-
Area Code
Phone Number
Plan Name
Insurance Company Name
Policy ID Number
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Group Name
Group Number
Insured Party Name
Relation
Birth Date
-
Month
-
Day
Year
Date
Insured Party Sex
Male
Female
Social Security Number
*
Insured Party Phone Number
-
Area Code
Phone Number
Insured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Medical Insurance Information
Employer / Business
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
-
Area Code
Phone Number
Plan Name
Insurance Company Name
Policy ID Number
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Group Name
Group Number
Insured Party Name
Relation
Birth Date
-
Month
-
Day
Year
Date
Insured Party Sex
Male
Female
Social Security Number
*
Insured Party Phone Number
-
Area Code
Phone Number
Insured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health History
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication 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.
Reason for today’s office visit?
What is your height?
What is your weight?
Are you in good health?
Yes
No
Have there been any changes in your general health in the past year?
Yes
No
Are you under the care of a physician?
Yes
No
Have you had any illness, operation or been hospitalized in the past five years?
Yes
No
Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
Yes
No
Do you have a prosthetic joint/implant?
Yes
No
Have you had a heart valve replacement or vascular graft?
Yes
No
Have you ever had general anesthesia?
Yes
No
Have you, or a family member, had any unusual or serious reactions to general anesthesia?
Yes
No
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Yes
No
Is there any condition concerning your health that the doctor should be told about?
Yes
No
Do you wish to speak to the doctor privately about anything?
Yes
No
If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?
Yes
No
Who is driving you home?
Health History Part 2
Have you ever had or do you currently have...
Yes
No
Rheumatic Fever
Damaged Heart valves / mitral valve prolapse
Heart murmur
High blood pressure
Low blood pressure
Chest pain/ agina
Heart Attack(s)
Irregular Heart Beat
Cardiac pacemaker
Heart Surgery
Pneumonia, bronchitis or chronic cough
Asthma
Hay fever / sinus problems
Snoring
Sleep Apnea / CPAP
Difficult breathing / other lung trouble
Tuberculosis
Emphysema
Do you smoke vape?
Do you use chewing tobacco?
Alcohol Intake?
Blood Transfusion
Blood disorder such as anemia
Bruoise easily
Bleeding tendency / abnormal bleed
Hepatitis, jaundice or liver disease
Infectious mononucleosis
Gallbladder Trouble
Fainting spells
Convulsions / epilepsy
Stroke
Thyroid Trouble
Diabetes
Low blood sugar
Kidney Trouble
High cholesterol
Are you on dialysis
Swollen ankles, arthritis or joint disease
Osteoporosis / Osteopenia
Osteonecrosis
Stomach Ulcers / Acid Reflux
COVID - 19
Contagious diseases
STDs
Problem with the immune system? Possibly from medication / surgery, etc
Autoimmine disease?
Delay in healing
A tumor in growth
Cancer / radiation therapy / chemotherapy
Chronic fatigue / night sweats
Are you on a diet
Is there a history / treatment for a marijuana or substance use disorder?
Contact lenses
Eye disease / glaucoma
Mental health problems / anxiety / depression
A removable dental appliance
Pain and clicking of jaws when eating
Medications / Allergies
Medications (Are you now taking...)
Yes
NO
Blood Thinners ( Coumadin, Plavix,Aspirin,Vitamin-E,Ginko biloba,Aggrenax,Xarelto, Eliquis, Fish Oil
Have you ever taken diet pills
Any natural product, herbal supplement or homeopathic remedy
Are you taking, or have you ever taken bone density meds, RANKL inhibiters or bisphosphonates such as Prolia, Fosamax, Bonita, Actonel, IV-Zometa, Aredua, Recleast, Xgeva or Evista in the past 12 years?
Have you. ever taken tranquillisers, sleeping pills, anti-depressants and/or narcotics on a regular basis? If yes, please list.
If you are under the care of a physician for pain management or recovering from drug addiction please select the medication you are currently taking:
Yes
No
Methadone
Suboxone
Oxycodone
Fentanyl
Other
Treating Doctor
First Name
Last Name
Are you allergic to or had a reaction to:
Yes
No
Local anesthetic ( numbing medication )
Penicillin
Other antibiotics
Sulfa Drugs
Sodium pentothal / Valium / other tranquillisers?
Aspirin
Amoxicillin
Codeine or narcotics
Latex
Soy
Eggs/Yolk
Sulfites
Do you have any known allergies?
Please list any allergies other than drug allergies:
Are you taking any kind of medication, drug or pills?
Yes
No
Please list any other medication or antibiotics you are allergic to
Conclusion
Is there a family history of:
Yes
No
Cancer
Diabetes
Heart Disease
Anesthesia Problems
Is this visit related to an accident?
Is this visit related to an accident
Yes
No
If yes what type?
Automobile
Work related
Other
Date of injury
-
Month
-
Day
Year
Date
Insurance Company
Insurance company handling this claim
Number
Insurance claim number
Attorney / Adjuster
Full Name
Attorney / Adjuster Number
Verification
I certify that I have read and I 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. Signature of the patient (Parent or Guardian if Minor)
Fees & Payment
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 is 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 for by your insurance company. You will be responsible for all collection costs, attorneys' fees, and court costs. Signature of the patient (Parent or Guardian if Minor)
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.Signature of patient (Parent or Guardian if Minor)
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 permit messages to be left on my phone and/or mobile phone concerning my appointment and 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 permit messages to be left on my phone and/or mobile phone concerning my appointment.
Signature of patient (Parent or Guardian if Minor)
I permit the office to communicate with me via text message on my cell phone.
Yes
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.
Signature of patient (Parent or Guardian if Minor)
Submit
Should be Empty: