Patient Registration Form

Patient Registration Forms

Oral & Maxillofacial Surgery
Your Privacy Is Protected

This form is HIPAA-compliant and meets all requirements for the secure handling of your personal health information. To protect your privacy:
- End-to-end encryption ensures that your responses are securely transmitted.
- Only authorized personnel will have access to your submissions.
- We do not share or sell your information to third parties.
By completing this form, you can feel confident that your information is handled with the highest level of privacy and care in accordance with federal HIPAA standards.

*Understand that any omission of necessary health information can endanger your life during surgery and lead to lethal complications.

**Social Security Numbers are needed to verify coverage of insurance benefits.

This form should take 5-10 mins.
What Office Do You Prefer?*

CupertinoLos Gatos
How did you hear about us?

Dr. ReferralFamily/FriendGoogleYelpOther
Name of Referrer (So we know who to thank!)

PrefixFirst NameLast Name

IN CASE OF EMERGENCY
Emergency Contact*
Relation*
Emergency Contact #*
Please enter a valid phone number.

SPOUSE OR OTHER GUARANTOR INFORMATION
WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT:*

SelfOther
Do you have a spouse or guarantor?*

YESNO
Name

First NameLast Name
Relation
Cell
Please enter a valid phone number.
Social Security #
*Required to verify insurance coverage
Birth Date

MonthDayYear
Date
Is spouse's address the same as patients address?*

YesNo
Address

Street Address

Apt / St #

CityState

Zip CodeCountry

PRIMARY DENTAL INSURANCE COMPANY
Do You Have Dental Insurance?*

YesNo
Employer*
Insurance Company Name*
I.D. #*
Tel.*
Please enter a valid phone number.
Group Name*
Group #*
Insured Party*
Relation*
Birth Date*

MonthDayYear
Date
Social Security #
*Required to verify insurance coverage
Tel.*
Please enter a valid phone number.
Sex*

MaleFemale
Address*

Street Address

Apt / St #

CityState

Zip Code

SECONDARY DENTAL INSURANCE COMPANY
Do You Have Secondary Insurance?*

YesNo
Employer*
Insurance Company Name*
I.D. #*
Tel.*
Please enter a valid phone number.
Group Name*
Group #*
Insured Party*
Relation*
Birth Date*

MonthDayYear
Date
Social Security #
*Required to verify insurance coverage
Tel.*
Please enter a valid phone number.
Sex*

MaleFemale
Address*

Street Address

Apt / St #

CityState

Zip Code

PRIMARY MEDICAL INSURANCE COMPANY
Do you have primary medical insurance you want to add?*

YesNo
Employer*
Insurance Company Name*
I.D. #*
Tel.*
Please enter a valid phone number.
Group Name*
Group #*
Insured Party*
Relation*
Birth Date*

MonthDayYear
Date
Social Security #
*Required to verify insurance coverage
Tel.*
Please enter a valid phone number.
Sex*

MaleFemale
Address*

Street Address

Apt / St #

CityState

Zip Code

I certify that I have read and 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.

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, attorney fees, and court costs.

INSURANCE PAYMENT AUTHORIZATION

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.

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.

NOTICE OF PRIVACY PRACTICES

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. (click here to see our Notice of Privacy Practices HIPAA form)
Patient Signature*

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Should be Empty:

	YES	NO
Are you in good health?
Have there been any changes in your general health in the past year?
Have you had any illness, operation or been hospitalized in the past five years? If so, please describe.
Do you have unhealed or inflamed areas, growths or sore spots in or around your mouth? If so, please describe.
Do you have any orthopedic prosthetic joints? If so, describe where.
Have you had a heart valve replacement or vascular graft/stents?
Have you ever had general anesthesia or IV sedation?
If yes, have you had any unusual reactions?
Has a physician recommended that you take antibiotics before any dental treatment?

	YES	NO
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?
Sinus problems?
Snoring?
Sleep apnea / CPAP?
Difficult breathing / other lung trouble?
Tuberculosis?
Emphysema?
Tobacco use?
Marijuana use?
Blood transfusion?
Blood disorder, such as enema?
Bruise easily?
Bleeding tendency / abnormal bleed?
Hepatitis, jaundice, or liver disease?
Infectious mononucleosis?
Gallbladder trouble?
Fainting Spells?

	YES	NO
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 ulcers / acid reflux?
Contagious disease diseases?
Sexually transmitted diseases?
Problems with immune system? Possibly from medication / surgery etc..
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 drug abuse?
Contact lenses?
Eye disease / Glaucoma?
Mental health problems / anxiety / depression?
A removable dental appliance?
Pain or clicking of the jaw joints when eating?

	YES	NO	N/A
Is there a possibility of pregnancy?
Expected delivery date?
Are you nursing?
Are you taking birth control pills?

	YES	NO	NOTES
Any kind of medication, drug, or pills?
Any Blood thinners, (i.e. Eliquis, Coumadin, Plavix, Aspirin, Aggrenox, Pradaxa, Vitamin E, Ginko biloba, Fish oil...)?
Have you ever taken diet pills? (i.e. Fen-phen)
Are you taking, or have you ever taken any medications for osteoperosis? (i.e. Fosamax, Boniva, Actonel,IV– Zometa, Aredia, Xgeva, Prolia, or Reclast...)
Are you taking any Tranquilizers, sleeping pills, anti-depressants, anti-anxiety, and/or narcotics on a regular basis? If so, please list.

Patient Registration Forms

PATIENT INFORMATION

IN CASE OF EMERGENCY

SPOUSE OR OTHER GUARANTOR INFORMATION

PRIMARY DENTAL INSURANCE COMPANY

SECONDARY DENTAL INSURANCE COMPANY

PRIMARY MEDICAL INSURANCE COMPANY

Health History

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING?

WOMEN ONLY

Medications

Allergies

	YES	NO	REACTION
Local anesthetic (numbing meds.)?
Penicillin?
Amoxicillin?
Sulfa drugs?
Other antibiotics?
Aspirin?
Sodium pentothal / Valium /other tranquilizers?
Codeine or other narcotics?
Latex?
Soy?
Eggs / Yolk?
Sulfites?
Do you have any known allergies?