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  • Associates for Oral, Maxillofacial, and Implant Surgery

  • PATIENT INFORMATION

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  • Spouse or other guarantor information

    (if different from above)

  • INSURANCE INFORMATION

  • PRIMARY DENTAL INSURANCE COMPANY

  • SECONDARY DENTAL INSURANCE COMPANY

  • PRIMARY MEDICAL INSURANCE COMPANY

  • 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.

  • HAVE YOU HAD OR DO YOU CURRENTLY HAVE. . .

  • MEDICATION – Are you now taking

  • If yes, please check the appropriate medication below

  • Is there a FAMILY HISTORY of

  • IN CASE OF EMERGENCY, CONTACT

  • THIS SECTION IS FOR WOMEN ONLY, MEN CONTINUE BELOW. WOMEN, CONTINUE BELOW WHEN YOU HAVE COMPLETED THIS SECTION

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  • Women Note:

    Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

  • 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 surgeon, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

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  • 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.

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