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New Patient Registration & Consent Form
Patient Full Legal Name:
*
Preferred Name:
Sex:
*
Male
Female
Email Address:
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
Weight:
Height:
Social Security #:
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone:
*
Format: (000) 000-0000.
Primary Phone Type
Mobine
Home
Work
Secondary Phone:
Format: (000) 000-0000.
Secondary Phone Type
Mobine
Home
Work
*Name of Emergency Contact:
*
Relationship:
*Emergency Contact:
*
Format: (000) 000-0000.
Emergency Phone Type
Mobine
Home
Work
Primary Dental Insurance:
Insurance Provider:
Group #:
Employer:
Policy/Member ID #:
Policy Holder Name:
Relationship to Patient:
DOB:
-
Month
-
Day
Year
Date
SSN:
Insurance phone number:
Format: (000) 000-0000.
Primary Medical Insurance:
Insurance Provider:
Policy / Member ID #:
Group #:
Do You Have Secondary Insurance Coverage:
Yes
No
Name of Referring Dentist/Physician:
Pharmacy Phone #
Format: (000) 000-0000.
Preferred Pharmacy Name:
Pharmacy Address:
Oral Surgery History + Anesthesia & Sedation Screening:
Have you had previous oral surgery?
Yes
No
Have you had complications with dental treatment or anesthesia?
Yes
No
Have you ever had IV sedation or general anesthesia?
Yes
No
Any history of nausea or vomiting with anesthesia?
Yes
No
Any family history of anesthesia problems?
Yes
No
Do you smoke, vape, or use tobacco products?
Yes
No
Do you use alcohol or recreational drugs?
Yes
No
Have you been prescribed narcotic pain medications before?
Yes
No
Did the prescribed narcotics work as intended?
Yes
No
If you answered yes on any question, please explain:
Medical History, Current Medications & Allergies: (Check all that apply)
Medical Conditions
Heart Disease
Diabetes
Stroke
High Blood Pressure
Bleeding Disorder
Seizures
Sleep Apnea
Asthma / COPD
Kidney Disease
Liver Disease
Thyroid Disorder
Cancer
Osteoporosis
Anxiety/Panic Disorder
Mental Health Condition
Pregnancy or Nursing
Other
Allergies
No known allergies
Medication allergies
Medication Allergies
Medication Allergies
Please list all medications, vitamins, and supplements you are currently taking:
*
I certify that I have read and understand the questions above. I acknowledge that my questions, if any, regarding the information set forth above have been answered to my satisfaction. I will not hold my doctor or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form.
We make every effort to keep the cost of your care as reasonable as possible. An estimate of charges for any procedure or surgery may be provided upon request. If you have dental and/or medical insurance, we are happy to submit claims on your behalf; however, insurance is considered a method of reimbursement to the patient and is not a substitute for payment. You are responsible for all deductibles, co-insurance, and any balance not paid by your insurance carrier. You are also responsible for all collection costs, attorney's fees, and court costs, if applicable.
I authorize the release of information necessary to process insurance claims and authorize payment of insurance benefits directly to the doctor for services rendered. I understand that Sierra Oral & Facial Surgery is opted out of Medicare and that I am entering into a private contract for my care.
I authorize my surgeon and designated staff to perform an oral and maxillofacial examination for diagnosis and treatment planning, including all necessary x-rays. If medically necessary, I authorize the release of information obtained during my examination and treatment to other healthcare providers and/or insurance carriers. I also permit messages to be left on my home and/or mobile phone regarding appointments. I acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me and that I have had the opportunity to ask questions.
Text Messaging Opt-In: By opting in, you agree to receive recurring text messages from Sierra Oral & Facial Surgery at the phone number provided. Messages may include appointment reminders, account updates, invitations to leave a review, and requests for feedback in the form of marketing surveys. Message frequency may vary. Standard Message and Data Rates may apply. You can reply STOP to unsubscribe or HELP for help. For questions, contact us at: (775) 285-6345. *No mobile information will be sold or shared with third parties for promotional or marketing purposes. We may share your Personal Data, including your SMS opt-in or consent status, with third parties that help us provide our messaging services, including but not limited to platform providers, phone companies, and any other vendors who assist us in the delivery of text messages. I consent and opt in to receive optional text messages from Sierra Oral & Facial Surgery.
Signature of Patient / Parent or Guardian (if minor):
*
Date:
*
-
Month
-
Day
Year
Date
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