Susanville SOFS New Patient Registration

Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Choose One
Patient's Name

First NameMiddle InitialLast Name
Sex:
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Soc. Sec.
E-mail
example@example.com
Mailing Address:
Apt.
City
State
Zip
Home Tel
Cell
Check all that apply:
Referred by:

First NameLast Name
Nearest relative not living with you:

First NameLast Name
Phone Number

Area CodePhone Number
Medical Doctor Name:
Dentist Name:
Orthodontist Name:
Employer
Bus. Tel
(555) 555-5555 x555
In case of emergency, please contact:
First and Last Name
Phone #:
Relation
Is the patient responsible for today's treatment?
Is the guarantor's address, same as patient?
SPOUSE OR OTHER GUARANTOR INFORMATION
Guarantor's Name:

First NameLast Name
Relation
SS#:
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:
Apt. (if applicable)
City
State
Zip
Phone #:
Employer
Bus. Tel
PHARMACY INFORMATION
Pharmacy Name
Pharmacy Address:
Check which applies:
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY DENTAL INSURANCE COMPANY
Insured Name:

First NameLast Name
Relationship:
Sex
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS #:
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Custody/Court Order in place?
Employer
Group Name
Insurance Company
ID
Type of Insurance:
PRIMARY MEDICAL INSURANCE COMPANY
Insured Name:

First NameLast Name
Relationship:
Sex
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS #:
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Custody/Court Order in Place?
Employer
Group Name
Insurance Company
ID
Type of Insurance:
SECONDARY DENTAL INSURANCE COMPANY
Insured Name:

First NameLast Name
Relationship:
Sex
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS #:
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Custody/Court Order in place?
Employer
Group Name
Insurance Company
ID
Type of Insurance:
SECONDARY MEDICAL INSURANCE COMPANY
Insured Name:

First NameLast Name
Relationship:
Sex
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS #:
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Custody/Court Order in place?
Employer
Group Name
Insurance Company
ID
Type of Insurance:
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications 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.
Reason for scheduled visit:
Height
Weight
Are you in good health?
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
If yes, please list the date of last visit and what you are being treated for:
Have you had any illness, operation or been hospitalized in the past five years?
If yes, please explain:
Do you have unhealed/recurrent injuries or inflames areas, growths or sore spots in or around your mouth?
If yes, please explain:
Do you have a prosthetic joint/implant/heart valve replacement?
If yes, please explain:
Have you ever had general anesthesia?
Have you, or a family member, had any unusual or serious reaction to general anesthesia?

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE:

Rows	Yes	No
Asthma
Difficulty breathing?
Other lung problems / cough?
A Pacemaker / heart valve replaced?
Heart problems?
Chest pain?
Irregular heart beat?
Heart Surgery?
Stroke?
Trouble climbing two flights of stairs?
High or Low Blood Pressure?
Sleep Apnea / Use CPAP?
Bleeding Disorder?
Bruise / Bleed easily?
Hepatitis / Liver Disease?
Faint easily?
Seizures?
Thyroid Trouble?
Diabetes?
Kidney problems?
Dialysis?
High Cholesterol?
Arthritis?
Osteoporosis?
Prosthetic joint?
Stomach ulcers / Reflux?
Immune system problems?
Slow healing?
Tumor or growth?
Cancer / Radiation / Chemo?
Eye disease / glaucoma?
Mental health problems / anxiety / depression?
Developmental Delay?
Removable dental appliance?
Pain or click of jaws?
Contagious Disease?
History of illicit drug use?
History of dependence or addiction to any substance?

Any other condition / problem not listed?
Please list any other condition/problem not listed:
Do you smoke?
If yes, # packs/day:
Do you use alcohol?
If yes, how much?
Are you pregnant or possibility of pregnancy?
Expected delivery date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you nursing?
Are you taking birth control?

ARE YOU NOW TAKING:

Rows	Not Satisfied	Somewhat Satisfied
Any kind of medication, drug, pills?
Blood Thinners (Courmadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish Oil)?
Diet Pills?
Natural products, herbal supplement, or homeopathic remedy?
Bone density meds, or Bisphosphonates (Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or Reclast in the past 12 years)?

Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list:
Please enter 'no' in this field if it's not applicable to you.
Are you currently on any medication?
Any other medication that you are currently taking (please list medication name, dosage, and frequency):

ARE YOU ALLERGIC TO, OR HAD A REACTION TO:

Rows	Yes	No
Local anesthetic (numbing meds.)?
Penicillin?
Other antibiotics?
Sulfa drugs?
Sodium pentothal / Valium / other tranquilizers?
Aspirin?
Amoxicillin?
Codeine or other narcotics?
Other medications?
Latex?
Soy?
Eggs / yolk?
Sulfites?

Do you have any known allergies?
Please list any allergies other than drug allergies:
Have you been prescribed narcotic pain medication?
If yes to previous question, did it work as intended in the past?
Family History (check all that apply):
If you are having surgery for your appointment, have you had anything to eat or drink in the last eight (8) hours?
Who is driving you home?
Is there any condition concerning your health that the Doctor should be told about?
If yes to previous question, please describe here:
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 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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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. I understand that Sierra Oral & Facial Surgery is opted out of Medicare and I am entering a private contract for my care.
Signature of patient (Parent or Guardian if Minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 appointment.
Signature of patient (Parent or Guardian if Minor)
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.
Signature of Patient (Parent or Guardian if Minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse To Sign This Acknowledgement**
I, blanks (your name) have received a copy of this office's Notice of Privacy Practices.
Patient Name
First and Last Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES