PATIENT INTAKE FORM
Troy Oral Surgery - Please complete the entire form.
Patient Name
Has the patient been under a physicians care
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
For what?
Patient Address
Name of Patients Dentist
City
State
ZIP
Name of Patients Physician
Phone Number: ( )
Format: 000 000-0000.
Email Address
example@example.com
Employer
Occupation
Name of Spouse or Parent
Dental Insurance
Insurance Co. Name (Dental)
Insureds Name (Primary)
D.O.B (Primary)
ID or SOC (Primary)
Secondary Insurance
Insureds Name (Secondary)
D.O.B (Secondary)
ID or SOC (Secondary)
Medical Insurance
Insurance Co. Name (Medical)
Insureds Name (Medical)
D.O.B (Medical)
ID or SOC (Medical)
Secondary Insurance (Medical)
Insureds Name (Secondary Medical)
D.O.B (Secondary Medical)
ID or SOC (Secondary Medical)
Person to Contact if Necessary
Name
Relationship
Phone Number: ( )
Format: 000 000-0000.
X I hereby certify that the above information is correct. Patient signature (if over 18) or parent/guardian
*
Date
/
Month
/
Day
Year
Date
Does the patient have Medication allergies?
Specify Allergies
Have you ever had any of the following:
Latex or Egg Allergy
YES:
NO:
Rheumatic Fever
YES:
NO:
Mitral Valve Prolapse
YES:
NO:
High Blood Pressure
YES:
NO:
Diabetes
YES:
NO:
Blood Disease
YES:
NO:
Prolonged Bleeding
YES:
NO:
Tuberculosis
YES:
NO:
Asthma
YES:
NO:
Bronchitis
YES:
NO:
Chemotherapy
YES:
NO:
Kidney Disease
YES:
NO:
Hepatitis
YES:
NO:
Liver Disease
YES:
NO:
Major Operation
YES:
NO:
Convulsions
YES:
NO:
Cortisone
YES:
NO:
Contact Lenses
YES:
NO:
Porphyria
YES:
NO:
HIV Positive
YES:
NO:
Do you smoke cigarettes?
YES:
NO:
Do you smoke marijuana?
YES:
NO:
Are you pregnant?
YES:
NO:
Are you taking birth control?
YES:
NO:
Are you taking Bisphosphonate medication?
YES:
NO:
Are you taking using any weight loss drugs like Ozempic,Trulicity, Wegovy, Saxenda, Victoza?
YES:
NO:
Specify if Ozempic,Trulicity, Wegovy, Saxenda, Victoza
Preferred Pharmacy
Pharmacy
Address
City
ZIP
Phone Number
Format: (000) 000-0000.
Medications being taken currently
Medications being taken currently (continued if needed)
Medications being taken currently (continued if needed)
Medications being taken currently (continued if needed)
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Home Tel
Emergency Contact Cell
Emergency Contact Relation
Accident Information
Is this related to an accident? Y / N
Please Select
N
Y
If Yes, what type?
Date of Injury
/
Month
/
Day
Year
Date
Insurance company handling this claim
Insurance Claim Number
Name of Attorney/Adjustor
Attorney/Adjustor Phone
Format: (000) 000-0000.
SIGNATURES
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.
*
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.
*
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.
*
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.
*
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.
*
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