Clone of NSCOFS: Patient Registration (English)

Title/Prefix

Name

First NameM.ILast Name

Sex

Birth Date

Date

Social Security Number

Please enter your social security number. This is often required to fully process your insurance claim.

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone

Please enter a valid primary phone number, either your cell phone or home phone.Format: (000) 000-0000.

Secondary Phone

If you have a secondary phone number you would like to include please list it here.Format: (000) 000-0000.

Email

example@example.com

Driver's License Number

Please enter your Driver's License Number if you have one.

Who were you referred by?

Please enter the name of your dentist who referred you to us or your friend/colleague.

Emergency Contact Full Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relation to Patient

Who will be responsible for your account?

Who is responsible for your account?

Responsible Individual Name

First NameLast Name

Responsible Individual Birth Date

Date

Responsible Individual SSN

Please enter the Social Security Number of the individual responsible for your account. This is often required to fully process your insurance claim.

Responsible Individual Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Responsible Individual Email

example@example.com

Responsible Individual Driver's License Number

Please enter the Driver's License Number of the individual responsible for your account.

Is the responsible individual's address different than the patient's address?

Responsible Individual Address

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Pharmacy Name

Please enter the name of your preferred pharmacy to pick up medications.

Preferred Pharmacy Address

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Pharmacy Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does the patient have dental insurance?

Do you have your dental insurance card or dental insurance information?

Who is the insurance subscriber?

Insurance Company Name

Insurance Company Phone

Please enter a valid phone number.Format: (000) 000-0000.

Group Number

Subscriber / Policy ID Number

Employer / Business Name

Subscriber / Policy Holder's Name (if other than patient)

First NameLast Name

Relationship of Policy Holder to Patient

Policy Holder's Birth Date

Date

Policy Holder's Sex

Policy Holder's Phone Number

Please enter a valid phone number for the policy holder.Format: (000) 000-0000.

Policy Holder's SSN

Please enter the social security number of the policy holder. This is often required to fully process your claim.

Is the policy holder's address different than the patient's address?

Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does the patient have medical insurance?

Do you have your medical insurance card or medical insurance information?

Who is the insurance subscriber?

Insurance Company Name

Insurance Company Phone

Please enter a valid phone number.Format: (000) 000-0000.

Group Number

Subscriber / Policy ID Number

Employer / Business Name

Subscriber / Policy Holder's Name (if other than patient)

First NameLast Name

Relation to Patient (if other than patient)

Policy Holder's Birth Date

Date

Policy Holder's Sex

Policy Holder's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Policy Holder's SSN

Please enter the social security number of the insured party.

Is the policy holder's address different than the patient's address?

Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

To our patients: Although we as 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.

Please describe the primary reason you have come to see us today.

Have you ever been diagnosed with a heart or blood vessel problem such as high blood pressure or irregular heartbeat?

Have you ever been diagnosed with a lung or breathing problem?

Have you ever been diagnosed with a brain, nerve, or neurological problem?

Have you ever been diagnosed with a hormone-related problem, such as diabetes or thyroid disease?

Have you ever been diagnosed with a blood disorder or a problem with bleeding or clotting?

Have you ever been diagnosed with a stomach, liver, or digestive problem?

Have you ever been diagnosed with a kidney problem?

Have you ever been diagnosed with a bone, joint, or autoimmune problem, including low bone density or osteoporosis?

Have you ever been diagnosed with a mental health condition such as anxiety or depression?

Have you ever been diagnosed with a sleep disorder, such as sleep apnea?

Have you ever been diagnosed with a serious or chronic infection such as hepatitis or HIV?

Have you ever been diagnosed with cancer or a tumor?

Have you been diagnosed with any other medical problem not listed above?

You selected "Yes" to a heart or blood vessel condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
High blood pressure (Hypertension)
Coronary artery disease
History of heart attack
Heart failure
Irregular heartbeat (Arrhythmia)
Valve disease / valve replacement
Congenital heart condition
Stroke or TIA
Peripheral vascular disease
Aneurysm
Other

You selected "Yes" to a lung or breathing condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Asthma
COPD / Emphysema
Chronic bronchitis
Shortness of breath
History of pneumonia
Tuberculosis
Other lung disease

You selected "Yes" to a brain, nerve, or neurological condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Seizures / Epilepsy
Stroke
TIA (mini-stroke)
Migraines
Multiple sclerosis
Parkinson’s disease
Trigeminal Neuralgia / Neuropathy
Dementia / memory disorder
Other

You selected "Yes" to a hormone-related condition, such as diabetes or thyroid disease - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Diabetes – Type 1
Diabetes – Type 2
Prediabetes
Thyroid disorder (Hypo/Hyper)
Adrenal disorder
Other hormone condition

You selected "Yes" to a blood disorder or a problem with bleeding or clotting - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Bleeding disorder (e.g., hemophilia, vWD)
History of excessive bleeding after surgery
Clotting disorder (DVT, PE)
Anemia
Low platelets
Other

You selected "Yes" to a stomach, liver, or digestive condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Acid reflux (GERD)
Ulcers
Liver disease (hepatitis, cirrhosis)
Pancreatitis
Inflammatory bowel disease (Crohn’s / UC)
Other

You selected "Yes" to a kidney condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Chronic kidney disease
Dialysis
Kidney transplant
Kidney stones
Other

You selected "Yes" to a bone, joint, or autoimmune condition including low bone density / osteoporosis - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Osteoporosis
Osteoarthritis
Rheumatoid arthritis
Lupus
Fibromyalgia
Other bone, joint, or autoimmune condition

You selected "Yes" to a serious or chronic infection - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Hepatitis B
Hepatitis C
HIV/AIDS
Tuberculosis
COVID-19 complications (long COVID if relevant)
Other chronic infection

You selected "Yes" to being diagnosed with cancer or a tumor - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Active cancer
History of cancer (in remission)
Radiation therapy (especially head/neck)
Chemotherapy
Bone metastases
Other

You selected "Yes" to a mental health condition - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Anxiety
Depression
Bipolar disorder
PTSD
Schizophrenia
Other

You selected "Yes" to a sleep disorder, such as sleep apnea - please select which condition you have been diagnosed with and add any relevant notes.

Rows	Diagnosed	Notes
Obstructive sleep apnea
Insomnia
Other sleep disorder
Do you use a CPAP?

You selected "Yes" to other conditions above. Please list any additional diagnosed conditions not already listed above.

Please list any other diagnosed conditions not listed above.

Do you have a family history of

Rows	Yes	No
Anesthesia Problems
Malignant hyperthermia
Unexpected death(s) following general anesthesia or exercise

Do you smoke or vape?

Alcoholic Drinks per Week

Please enter the approximate number of alcoholic drinks you consume in a week.

Women Only...

Rows	Yes	No
Are you currently pregnant or is there a possibility you are currently pregnant?
Are you nursing?
Are you taking birth control pills?

Expected Delivery Date

If you are currently pregnant please list your anticipated delivery date.

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

Are you allergic to or have you ever had a reaction to:

Rows	Yes	No	Notes
Local anesthetic (numbing medication)
Penicillin or Amoxicillin
Other antibiotics
Codeine or other narcotics
Latex
Do you have any other known drug allergies?

Are you currently taking any kind of medication, drug, or pill?

Do you currently receive any injections or infusions for weight loss, osteoporosis/low bone density, or pain management/addiction, or have you ever received any of these injections or infusions in the past?

Medications - are you currently taking:

Rows	Yes	No
Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Xarelto, Eliquis, Fish oil)
Any weight loss medications or injections?
Any natural product, herbal supplement or homeopathic remedy
Are you taking, or have you ever taken bone density medications used to treat osteoporosis? Examples include infusions such as Prolia and Reclast as well as oral medications such as Prolia, Fosamax, Boniva, Actonel, Zometa, Aredia, Reclast, Xgeva, or Evista.

Please list all medications you are currently taking. If the list is long you may skip this step and bring your list of medications with to your appointment.

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis?

Please list the tranquilizers, sleeping pills, anti-depressants and/or narcotics you have taken on a regular basis:

Are you currently under the care of a physician for pain management, or recovering from drug addition?

If you are under the care of a physician for pain management, or recovering from drug addiction please select any medications you are currently taking:

Rows	Currently taking
Methadone
Suboxone
Oxycodone
Fentanyl
Other

Treating doctor

If you are currently being treated for pain management, please provide the name of your pain management doctor.

If you are planning on having same-day surgery with intravenous sedation, please list the name of the friend/family member who will be driving you home and their relationship to you:

Driver's Name / Relationship

Is there any other condition concerning your health that the doctor should be told about?

If so, please describe

Is this visit related to an accident?

If Yes, What type?

Date of Injury

Date

Insurance company handling claim

Insurance Claim Number

Name of Attorney/Adjustor

Attorney/Adjustor Phone

Please enter a valid phone number.Format: (000) 000-0000.

VERIFICATION

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.

Signature of patient (Parent or Guardian if Minor)

Date

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, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

Date

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.

Signature of patient (Parent or Guardian if Minor)

Date

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. I permit messages to be left on my phone and / or mobile phone concerning my appointments.

Signature of patient (Parent or Guardian if Minor)

Date

AUTHORIZATION TO RELEASE PHOTOGRAPHS

I authorize staff at NorthShore Center for Oral and Facial Surgery to take and use photographs, digital images, and/or videos of me for:

Rows	Yes	No
Medically necessary case documentation and education
Website, educational brochures, etc.

I understand that once my photograph(s), digital image(s), and/or video(s) have been released, this practice may no longer have control over them, and federal or state privacy laws may no longer protect the information that was released.

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know that canceling this authorization would not prohibit any release of photographs by the doctor or practice in reliance on my original authorization.

To cancel this agreement, I must write a letter to the doctor or practice advising of my wish to cancel my authorization to disclose photographs taken of me by this practice. I (or my authorized representative) must sign and date the letter.

Once my doctor gives out any photographs I have approved, I know that my doctor has no control over them. Federal or state privacy laws may no longer protect the information.

Signature of patient (Parent or Guardian if Minor)

Date

Relationship of signer to patient

CANCELLATION POLICY

Cancellation of scheduled surgeries requires a minimum of 48-hour notice. Due to the necessary supplies and equipment allotted for surgical procedures, any cancellation not made prior to the 48 hours will be subject to a fee of $75.00 per scheduled 15 minutes to your account. This fee will not be billed to your insurance.

Signature of patient (Parent or Guardian if Minor)

Date

PATIENT CONSENT FORM AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our Business Office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations, including leaving messages on your home, cell and/or work answering machines. You have the right to revoke this consent, in writing, except where we have already made disclosure in reliance on your prior consent.

Do you wish to authorize release of your protected health information to another individual?

Name of Individual to Release Protected Health Information To:

Relationship to Patient

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I understand that photographs, videotapes, digital or other images may be recorded to document my care, and I consent to this. I understand that doctors and staff of NorthShore Center for Oral and Facial Surgery (NSCOFS) will retain the ownership rights to these photographs, videotapes, digital or other images, but that I will be allowed access to view them and obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the period of time required by law as outlined in NorthShore Center for Oral and Facial Surgery (NSCOFS)’s policy. Images that identify me will be released and/or used outside the office only upon written authorization from my legal representative or me.

In signing this form, I acknowledge having reviewed/received a copy of this office’s Notice of Privacy Practices (click here to see our Notice of Privacy Practices) and also give my consent to the above.

QUADAA - We are an accredited QUADAA facility. If you have questions or would like additional information, you may request a copy of the “QUADAA Policies and Rights” electronically or by visiting our office and picking up a copy.

Name

First NameLast Name

Signature of patient (Parent or Guardian if Minor)

Date

Patient Registration Form

Patient's Information

Who will be responsible for your account?

Pharmacy Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Health History

Review of Systems

Medications / Allergies

Conclusion