Patient Information Package

  • Patient Information Package

    Northeast Arkansas Center for Oral & Maxillofacial Surgery

  • Health History

  • Date of Birth
     - -
  • Gender

  • Your medical history is important to the treatment you will receiv. Therefore, it is important that you respond to each question honestly and completely.

  • Please describe your health
  • Have there been any changes to your general health in the past year?
  • Are you now under a physician's care for a particular problem at this time?
  • Have you even been hospitalized or had a serious illness?
  • Date of last physical exam
     - -

  • Patient Medical History

  • Do you have or have you ever had:

  • Congenital heart disease, cardiovascular disease (heart attack, heart murmur, coronary artery disease, chest pain, high/low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)?
  • Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)?
  • Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?
  • Glaucoma?
  • Kidney disease or kidney failure, requiring dialysis?
  • Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?
  • Thyroid disease?
  • Liver disease (Jaundice, hepatitis A, B, or C)?
  • Stomach ulcers or colitis?
  • Diabetes?
  • Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?
  • Arthritis?
  • Frequent or recurring mouth sores?
  • Significant weight loss or gain?
  • Radiation to the head or neck for cancer treatment?
  • Seizures, convulsions, epilepsy, fainting or dizziness?
  • Any disease, chemotherapy or transplant operation?
  • Date of last treatment
     - -
  • Sinus or nasal problems?
  • Osteoporosis or osteopenia?
  • Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

  • Family Medical History

  • Do you have a family history of any of the following? If yes, indicate the relationship.

  • Diabetes
  • Cancer
  • Heart Disease
  • Bleeding problems
  • Tumors
  • Lung disease

  • Female Patients

  • Are you pregnant, or is there any chance you might be pregnant?

  • Medications

  • Are you using any of the following?

  • Antibiotics
  • Aspirin or drugs such as Motrin, Aleve, Ibuprofen
  • Anticoagulants (blood thinners)
  • Insulin or oral anti-diabetic drugs
  • Heart drugs
  • High blood pressure medications
  • Steroids (cortisone, prednisone, etc.)?
  • Bisphosphonates, antiangiogenic, and/or antiresorptive medications for osteoporosis, multiple myeloma or other cancers?
  • Prescription pain medication?

  • Allergies

  • Are you using any of the following?

  • Latex
  • Codeine or other pain killers
  • Food products
  • Aspirin, Motrin, Aleve, or Ibuprofen
  • Sedatives, barbiturates
  • Penicillin or other antibiotics
  • Have you or an immediate family member had any problems associated with local anesthesia, general anesthesia and/or intravenous sedation?

  • Social History

  • Have you ever smoked or chewed tobacco?

  • Have you ever sought professional care or been hospitalized for:

  • Drug abuse?
  • Emotional disorder?
  • Alcoholism?

  • Do you use:

  • Alcohol?
  • Marijuana?
  • Recreational drugs?

  • Dental History

  • Have you had any adverse effects from dental treatment?
  • Do you wish to talk to the doctor privately about anything?
  • Date*
     - -

  • Patient Information (If Over 18 Y/O)

  • Gender
  • DOB
     - -
  • Format: (000) 000-0000.
  • Would you like to be confirmed via text or email?
  • Format: (000) 000-0000.

  • Person to Contact in Case of Emergency

  • Format: (000) 000-0000.

  • Medical Insurance

  • Format: (000) 000-0000.
  • Insured's DOB
     - -

  • Dental Insurance

  • Format: (000) 000-0000.
  • Insured's DOB
     - -
  • Date*
     - -

  • Patient Information (If Under 18 Y/O)

  • Gender
  • DOB
     - -

  • Parent's/Legal Guardian Information

  • DOB
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • DOB
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to be confirmed via text or email?

  • Medical Insurance

  • Format: (000) 000-0000.
  • Insured's DOB
     - -

  • Dental Insurance

  • Format: (000) 000-0000.
  • Insured's DOB
     - -
  • Date
     - -

  • Patient Disclosure Instructions

  • In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

  • I wish to be contacted in the following manner (check all that applies):
  • For Home Telephone
  • Format: (000) 000-0000.
  • For Written Communication
  • I allow you to give my clinical information to or answer questions from (check all that applies):

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY&nbspPRACTICES

    NORTHEAST ARKANSAS CENTER FOR ORAL AND MAXILLOFACIAL SURGERY

  • If you wish to obtain a copy of our privacy practices, please inform the staff upon returning this form.

    I have received a copy of Northeast Arkansas Center for Oral and Maxillofacial Surgery, Notice of Privacy Practices which describes how my health information is used and shared. I understand that Northeast Arkansas Center for Oral and Maxillofacial Surgery, has the right to change this notice at any time. I may obtain a current copy by contacting the Facility Privacy Officer, or by visiting the Facility website at www.neaoralsurgery.com.

    In the event of a medical emergency, NEA Center for Oral and Maxillofacial Surgery does not accept advance directives for non-resuscitation. Advanced directives will be included with transfer to a higher level of care if provided.

    Questions concerning this policy can be directed to the clinic manager; Medicare.gov or Arkansas Code Title 20-6-103.

    My signature below acknowledges a copy was offered/received. (Not necessarily read).

  • Date*
     - -

  • Facility Use Only

    If the patient or patient's representative is unwilling or unable to sign this Acknowledgement, state the reason and describe the steps taken to obtain the signature.
  • Date*
     - -

  • Patient No-Show, Late Show, and Cancellation Policy

  • Dear Patient:

    When we make your appointment, we are reserving a time slot for you with the doctor. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible for us for us to give your reserved slot to another patient.

    We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that session. In addition, rushing or "squeezing in" an appointment shortchanges the patient and contributes to decreased quality of care (and increases medical errors). In light of this, patients arriving more than 5 minutes after their appointment time will be asked to reschedule. We apologize for any inconvenience this might cause.

    Repeated cancellations or missed appointments will result in loss of all future appointment privileges.

    By implementing this policy, we believe we honor patients who schedule/keep appointments, while also trying to accommodate everyone inn a fair and efficient manner. Thank you for your cooperation.

     

  • Date*
     - -
  • Should be Empty: