Patient Registration Form

Patient Registration

Babston Oral Surgery · 100 S University Blvd. Suite A Mobile, Alabama 36608
PATIENT INFORMATION
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Birthdate*

MonthDayYear
Date
Social Security #
Height*
Weight*
Sex*
Cell Number*
Please enter a valid phone number.
New or returning patient?*

New PatientReturning Patient
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Dentist/Orthodontist
Primary Care Physician

PATIENT AUTHORIZATION & CONSENT
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.

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. have been given the opportunity to ask any questions I may have regarding this Notice.
Signature of Patient (Legal Guardian, if minor)

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
Damaged heart valves/mitral valve prolapse
Heart murmur
High blood pressure
Low blood pressure
Chest pain / angina
Heart attack(s)
Irregular heart beat
Cardiac pacemaker
Heart surgery
Asthma
Sleep apnea / CPAP
Difficulty breathing / other lung trouble
Tuberculosis
Emphysema
Blood disorder such as anemia
Bleeding tendency / abnormal bleed
Hepatitis, jaundice, or liver disease
Infectious mononucleosis
HIV / AIDS
Fainting spells
Convulsions / epilepsy
Stroke
Thyroid trouble
Diabetes (Type 1)
Diabetes (Type 2)
Low blood sugar
Kidney trouble
High cholestorol
Joint replacement
Osteoporosis / Osteopenia
Osteonecrosis
Contagious diseases
Sexually transmitted diseases
Problems with immune system
Delay in healing
Delay in healing
Cancer, radiation therapy, or chemotherapy
History of marijuana or other drug use
Mental health problems
Removable dental appliance
Pain or clicking of jaws when eating
Do you smoke or vape

	Yes	No
Are you pregnant or trying to become pregnant?
Are you currently nursing?
Are you currently taking birth control?

	Yes	No
Blood thinners (Coumadin, Plavix, Aspirin, etc.)
Bone density medications, RANKL inhibitors, or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years

	Yes	No
Local anesthetic (numbing medication)
Penicillin
Sulfa drugs
Sodium pentothal / Valium
Aspirin
Codeine
Latex
Soy
Eggs / Yolk
Sulfites

Patient Registration

	Yes	No
Family history of cancer?
Family history of diabetes?
Family history of heart disease?
Family history of anesthesia problems?
Is there any condition concerning your health that the doctor should be told about?
Do you wish to speak to the doctor privately about anything?