Midtown Oral New Patient Form - Dr. James Jackson

OMS New Patient Form
Patient Info
Today's Date*

MonthDayYear
Date
Patient Name*

First NameMiddle InitialLast Name
Sex*

MaleFemale
Birth Date*

MonthDayYear
Date
Social Security*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number (If different from home phone)
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever been a patient of our practice?*

YesNo
Referred By

First NameLast Name
Has a family member ever been a patient of our practice?*

YesNo
Dentist

First NameLast Name
Orthodontist

First NameLast Name
Medical Doctor

First NameLast Name
Preferred Pharmacy
Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Driver's License
Driver's License Number
Nearest Relative Not Living With You
Relative Name

First NameLast Name
Relative Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Info
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Payment Type

CashCheckCredit Card
Emergency Contact Info
In case of emergency, please contact

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relation
Who Will Be Responsible For Your Account
Responsible Party (If SELF, skip the following section)

SelfSpouseFatherMotherOther
Name

First NameLast Name
Social Security
Birth Date

MonthDayYear
Date
Age
Tel. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License Number
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Or Guardian Info
Name

First NameLast Name
Relation
Social Security
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Info
Student Status
Student?

Full TimePart TimeNot
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Married?

MarriedDivorcedWidowSingleLegally Separated
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Status
Employed?

Full TimePart TimeRetiredNot
Do you belong to a PPO or HMO?

YesNo
Primary Dental Insurance Company
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Plan
Insurance Company Name
Insurance Company ID Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group Name
Group Number
Insured Party Full Name

First NameLast Name
Insured Party Relation
Insured Party Social Security Number
Insured Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Medical Insurance Company
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Plan
Insurance Company Name
Insurance Company ID Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group Name
Group Number
Insured Party Full Name

First NameLast Name
Insured Party Relation
Insured Party Social Security Number
Insured Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Dental Insurance Company
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Plan
Insurance Company Name
Insurance Company ID Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group Name
Group Number
Insured Party Full Name

First NameLast Name
Insured Party Relation
Insured Party Social Security Number
Insured Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Medical Insurance Company
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Plan
Insurance Company Name
Insurance Company ID Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group Name
Group Number
Insured Party Full Name

First NameLast Name
Insured Party Relation
Insured Party Social Security Number
Insured Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that youmay have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank youfor answering the following questions. Your answers are for our records only and will be considered confidential.
Reason for today’s office visit?
Height
Weight
Are you in good health?

YesNo
Are you under the care of a physician?

YesNo
If so, for what are you being treated?
Date of last visit

MonthDayYear
Date
Have you had any illness, operation or been hospitalized in the past five years?

YesNo
If so, describe:
Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

YesNo
If so, describe where:
Do you have a prosthetic joint / implant?

YesNo
If so, describe where:
Have you had a heart valve replacement or vascular graft?

YesNo
Have you ever had general anesthesia?

YesNo
Have you, or a family member, had any unusual or serious reactions to general anesthesia?

YesNo
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

YesNo
Have You Had, Or Do You Currently Have:
Rheumatic fever?*
Damaged heart valves / mitral valveprolapse?*
Heart murmur?*
High blood pressure?*
Low blood pressure?*
Chest pain/angina?*
Heart attack(s)?*
Irregular heart beat?*
Cardiac pacemaker?*
Heart surgery?*
Pneumonia, bronchitis, chronic cough?*
Asthma?*
Hay fever/sinus problems?*
Snoring?*
Sleep apnea/CPAP?*
Difficult breathing/other lung trouble?*
Tuberculosis?*
Emphysema?*
Do you smoke or vape?If so, how much a day (Add to Notes)*
Do you use chewing tobacco?*
Blood transfusion?*
Blood disorder such as anemia?*
Bruise 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/joint disease?*
Osteoporosis/osteopenia?*
Osteonecrosis?*
Stomach/acid reflux?*
Contagious diseases?*
Sexually transmitted diseases?*
Problems with immune system?Possibly from medication/surgery, etc.*
Delay in healing?*
A tumor or growth?*
Cancer/radiation therapy/chemotherapy?*
Chronic fatigue/night sweats?*
Are you on a diet?*
A history of alcohol abuse?*
A history of marijuana or other drug use?*
Contact lenses?*
Eye disease/glaucoma?*
Mental health problems/anxiety/depression?*
A removable dental appliance?*
Pain or clicking of jaws when eating?*
Women ONLY:
Is there a possibility of pregnancy?

YesNo
Expected delivery date?

MonthDayYear
Date
Are you nursing?

YesNo
Are you taking birth control pills?

YesNo
Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.
Are You Now Taking:
Any kind of medication, drug, pills?*
Blood thinners (Coumadin, Plavix,Aspirin, Vitamin E, Ginko biloba,Aggrenox, Pradaxa, Fish oil)?*
Have you ever taken diet pills?*
Any natural product, herbalsupplement or homeopathic remedy?*
Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?*
Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on aregular basis? If so, please list:
If you are under the care of a physician for pain management, orrecovering from drug addiction please select the medication you are currently taking:

MethadoneSuboxoneOxycodoneFentanylOther
Treating Doctor (If you answered YES to the previous question)

First NameLast Name
Please list any medications you are currently taking:*
Are You Allergic To, Or Had A Reaction To:
Local anesthetic (numbing meds.)?*
Penicillin?*
Other antibiotics?*
Sulfa drugs?*
Sodium pentothal/Valium/other tranquilizers?*
Aspirin?*
Amoxicillin?*
Codeine or other narcotics?*
Latex?*
Soy?*
Eggs / yolk?*
Sulfites?*
Do you have any known allergies?*
Please list any allergies other than drug allergies:
Please list any other medication or antibiotic you are allergic to: (Medication / Antibiotic Name)
If you are having surgery today, have you had anything to eat or drinkin the last 6 (six) hours?

YesNo
Who is driving you home?
Is there any condition concerning your health that the Doctor should be told about?

YesNo
If Yes, describe:
Do you wish to speak to the Dr. privately about anything?

YesNo
Is there a family history of:

CancerDiabetesHeart diseaseAnesthesia problems
Is this visit related to an accident?

YesNo
If Yes, what type of accident?

AutomobileWork relatedOther
Date of injury

MonthDayYear
Date
Insurance company handling the claim:
Claim number:
Name of attorney/adjustor:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 patient (Parent or Guardian if Minor)
Date

MonthDayYear
Date
Reviewed by
Date

MonthDayYear
Date
Fees & Payments
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 patient (Parent or Guardian if Minor)
Date

MonthDayYear
Date
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)
Date

MonthDayYear
Date
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.
Signature of patient (Parent or Guardian if Minor)
Doctor
Date

MonthDayYear
Date
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)
Date

MonthDayYear
Date
Should be Empty:

OMS New Patient Form

Patient Info

Preferred Pharmacy

Driver's License

Nearest Relative Not Living With You

Employer Info

Emergency Contact Info

Who Will Be Responsible For Your Account

Spouse Or Guardian Info

Insurance Info

Student Status

Marital Status

Employment Status

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Company

Secondary Medical Insurance Company

Medical History

Have You Had, Or Do You Currently Have:

Women ONLY:

Are You Now Taking:

Are You Allergic To, Or Had A Reaction To:

Fees & Payments

Authorization