• St. Augustine Oral & Facial Surgical Center

  • Demographics Form

  • If Student
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is the patient the guarantor?*

  • GUARANTOR

    (If different from patient)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PHYSICIANS

  • PREFERRED PHARMACY

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTAL INSURANCE

  • Do you have dental insurance?*
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  • Do you have secondary dental/medical insurance?*

  • MEDICAL INSURANCE

  • Format: (000) 000-0000.
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  • AUTHORIZATION, RELEASE & AGREEMENT TO PAY FOR SERVICES RENDERED

  • I authorize the doctor and other dentists or health-care professionals (interdisciplinary team members) to perform diagnostic procedures and treatment as may be necessary for proper dental-facial care. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment and to use the same by the doctor or interdisciplinary team members in scientific presentations or scientific literature. I authorize St. Augustine Oral and Facial Surgery Center to release any information (via mail, fax, phone, or email) including the diagnosis and the records of any treatment or examination rendered to me/my child during the period of such Dental/Medical care to third-party payers, and other entities and/or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents.

  • CANCELLATION POLICY

  • Please note that a cancellation fee is charged if you don't show up for your appointment or if you cancel or reschedule your appointment without giving a minimum of 48 hours notice prior to the start of the appointment. To reschedule your appointment, please get in touch with our office on (904) 439-7980 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Health History

    (ALL RESPONSES ARE KEPT CONFIDENTAIL)

  • Please answer all questions

  • Are you in good health*
  • Has there been any change in your general health in the past year?*
  • Date of last physical exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you now under a physician’s care or a particular problem*
  • Have you ever had any serious illnesses, operations or hospitalizations?*

  • Are you allergic or have you had an adverse reaction to:

  • Local Anesthesia (Novocain etc….)*
  • Penicillin or other antibiotics*
  • Sedatives or barbiturates*
  • Aspirin or Ibuprofen*
  • Codeine or other pain killers*
  • Latex or rubber gloves*
  • Other allergies or reactions*
  • Do you take or have you ever taken any bisphosphonates: Editronate (didronel), Tiludronate (Skelid), Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva), Pamidronate (Aredia), Zoledronate (Zometa), Zoledronic acid (Reclast), Denosumab (Prolia), Bevacizumab (Avastin)*
  • Do you smoke or chew tobacco*
  • Is there any past history of alcohol or chemical Dependency or emotional disorders that may effect the care we provide*
  • Have you or any immediate family member had any problem associated with intravenous anesthesia?*
  • Do you have any other disease, condition or problem not listed above that the doctor should know about?*
  • Do you wish to talk to the doctor privately about anything?*

  • Do you have or have you ever had :

  • Heart (Surgery, disease, attack, Pacemaker)*
  • High Blood Pressure*
  • Chest Pain*
  • Heart Murmur*
  • Mitral Valve Prolapse*
  • Rheumatic Fever*
  • Swollen Ankles*
  • Active Tuberculosis*
  • Prolonged Cough 3-4 weeks*
  • Bloody Cough*
  • Unexplained weight loss*
  • Night sweats*
  • Emphysema*
  • Other respiratory illness*
  • Asthma*
  • Seizures, Epilepsy, or Convulsions*
  • Fainting or Dizziness*
  • Bleeding disorder, Anemia, Bleeding tendency or Blood transfusion*
  • Do you bruise easily*
  • Liver Disease (Jaundice, Hepatitis)*
  • Kidney Disease*
  • Diabetes*
  • Thyroid Disease (Goiter)*
  • Arthritis*
  • Glaucoma*
  • Implants Placed anywhere in your body*
  • Radiation (X-Ray) treatment for Cancer Jaw Pain or clicking, popping, difficulty*
  • Difficulty opening, grinding, clenching teeth*
  • Sinus or nasal problems*
  • Any disease, drug, or transplant operation that has depressed your immune system*
  • Syphilis*
  • Venereal Disease*
  • Herpes*
  • AIDS*
  • Cold Sores/Fever blisters*

  • FOR WOMEN ONLY

  • Are you pregnant, or is there a chance you might be?*
  • Are you on Depo-Provera Injections?*

  • Medication Reconciliation Record

    Please list all prescriptions, over the counter, vitamins, and herbal/natural medications that you are currently taking.

  • NOTE: (Last two columns to be completed by Dr. Johnson) 

  • Click "Add Row" for more add (if you are not taking any medications, type none)*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Notice of Privacy Practices

  • This notice describes how Medical/Protected Health Information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    Summary: By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain your information.

    As a patient, you have the following rights:

    1. The right to request and copy your information;
    2. The right to request corrections to your information;
    3. The right to request your information to be restricted;
    4. The right to request confidential communication;
    5. The right to report of disclosures of your information; and
    6. The right to a paper copy of this notice.

    We want to assure you that your medical/protected health information is secure with us. This notice contains information about how we will insure that your information remains private.

    If you have any questions about this notice, please contact our office, at 904-460-0505.

  • Acknowledgement of Notice of Privacy Practices

  • “I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I understand that if I have any questions or complaints regarding my privacy rights that I may contact the office number listed above. I further understand that the practice will offer me updates to the Notice of Privacy Practices should it be amended, modified, or changed in any way.”

    You may authorize certain individuals to be involved in your care. This consent for disclosure includes both health and financial information as it relates to your care. Below you may list those individuals for which our office is allowed to release your Protected Health Information.

     

  • Advanced Directives Notice

  • Please sign below to show that you are aware that our office does not honor Advance Directives. However, if you would like a Living Will Statement, please request a copy from a staff member.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: