Step 1 of 8 12% General Patient InformationDate SalutationDrMrMrsMissMsFirst nameMiddle initialLast nameNicknameSexMaleFemaleBirthdate AgeSocial security numberCell phone numberWork phone numberDrivers license numberEmail AddressCityStateFloridaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipDentistPhysicianReferred byNearest relative not living with youPhone number of nearest relative not living with youEmployerBusiness phone numberExtEMERGENCY CONTACTName of emergency contactCell phone number of emergency contactWork phone number of emergency contact RESPONSIBLE FOR ACCOUNTFinancially responsible partySelfOtherFull name of financially responsible partyRelationship to patientBirthdate of financially responsible party Age of financially responsible partySocial security number of financially responsible partyCell phone number of financially responsible partyAddress of financially responsible partyCity of financially responsible partyState of financially responsible partyFloridaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of financially responsible partyEmployer of financially responsible partyBusiness phone number of financially responsible partyPhone extension INSURANCE INFORMATIONMarital statusSingleMarriedWidowedDivorcedLegally separatedPrimary Dental InsuranceName of primary dental insurance companyPhone number of primary dental insurance companyName of primary dental insuredRelationship of primary dental insured to patientSex of primary dental insuredMaleFemaleBirthdate of primary dental insured Social security number of primary dental insuredID number of primary dental insuredGroup number of primary dental insuredPrimary Medical InsuranceName of primary medical insurance companyPhone number of primary medical insurance companyName of primary medical insuredRelationship to patient of primary medical insuredSex of primary medical insuredMaleFemaleBirthdate of primary medical insured Social security number of primary medical insuredID number of primary medical insuredGroup number of primary medical insured I consent to the dental practice using my cell phone number to call or text regarding appointments and to call regarding treatment or insurance or my account Choose one or both Call Text My cell number if different from aboveInitial Medical HistoryALLERGIESAre you allergic or have you had a bad reaction to any of the following?Local anesthetic or numbing medicationYesNoPenicillinYesNoOther antibioticsYesNoSulfa drugsYesNoSodium pentothal or Valium or other tranquilizersYesNoAspirinYesNoCodeine or other narcoticsYesNoLatexYesNoSoyYesNoEggs or yolkYesNoSulfitesYesNoPlease list all known allergies and reactions to medications I have no known allergies MEDICATIONSAre you taking or have you taken any of the following?Blood thinners such as Coumadin or Plavix or Aspirin or vitamin E or ginko bilobaYesNoDiet pillsYesNoAny bone density medications or bisphosphonates such as Aredia or Zometa or Fosamax or Actonel or Evista or Prolia or ForteoYesNoTranquilizers or sleeping pills or anti-depressants or narcotics on a regular basisYesNoIf so please listPlease list all current medications including non-prescription or homeopathic and natural remedies Currently taking no medications Medical History (Cont)Reason for todays office visitAre you in good health?YesNoHas there been any change in your general health in the past year?YesNoAre you now under the care of a physician?YesNoIf yes for what condition?Date of last visit Have you had any serious illness or operations or hospitalizations in the past five years?YesNoIf yes please explainDo you have unhealed or recurrent injuries or inflamed areas or growths or sore spots in or around your mouth?YesNoIf yes please explain and describe whereDo you have a prosthetic joint or implant?YesNoIf yes please describe whereHave you had a heart valve replacement or vascular graft?YesNoAre you on a diet?YesNoDo you wear contact lenses?YesNoDo you wear a removable dental appliance?YesNoHave you had or do you currently have:Rheumatic fever?YesNoDamaged heart valve or mitral valve prolapse?YesNoHeart murmur?YesNoHigh blood pressure?YesNoLow blood pressure?YesNoChest pain or angina?YesNoHeart attack or heart attacks?YesNoIrregular heart beat?YesNoCardiac pacemaker?YesNoHeart surgery?YesNoBronchitis or chronic cough?YesNoAsthma?YesNoHay fever or sinus problems?YesNoSnoring or sleep apnea?YesNoDifficult breathing?YesNoOther lung trouble?YesNoTuberculosis?YesNoEmphysema?YesNoBlood transfusion?YesNoAnemia or other blood disorder?YesNoBruise easily?YesNoBleeding tendency?YesNoHepatitis or jaundice or liver disease?YesNoInfectious mononucleosis?YesNoGallbladder trouble?YesNoFainting spells?YesNoConvulsions or epilepsy?YesNoStroke?YesNoThyroid trouble?YesNoDiabetes?YesNoLow blood sugar?YesNoOn dialysis?YesNoSwollen ankles or arthritis or joint disease?YesNoOsteoporosis or osteopenia?YesNoOsteonecrosis?YesNoContagious diseases?YesNoSexually transmitted diseases?YesNoDisease or drug or transplant that has suppressed your immune system?YesNoImmune system trouble or problems from medication or surgery?YesNoDelay in healing?YesNoStomach ulcers?YesNoKidney trouble?YesNoEye disease or glaucoma?YesNoTumor or growth?YesNoRadiation therapy or chemotherapy?YesNoChronic fatigue or night sweats?YesNoMental health problems?YesNoPain or clicking of jaws when eating?YesNoMalignant hyperthermia?YesNoSmoke or chew tobacco?YesNoHistory of drug abuse?YesNoHistory of alcohol abuse?YesNoNotes for any of the above checkedIs there a family history of:Cancer?YesNoDiabetes?YesNoHeart disease?YesNoAnesthetic problems?YesNoDid you wish to speak to the doctor privately about anything?YesNoIs there any condition concerning your health that the doctor should be told about?YesNoIf yes please describe Medical History (Cont)VISIT RELATED TO ACCIDENTIs this visit related to an accident?YesNoIf yes was it anAutomobile accident?Work related accident?Other accident?Date of injury? Insurance company handling this claimClaim numberName of attorney or adjustorPhone number of attorney or adjustorWOMEN ONLYAre you pregnant or is there any chance you might be pregnant?YesNoIf yes expected delivery date Are you nursing?YesNoAre you taking birth control pills?YesNo Fees & Payments 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. 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. Authorization I authorize my surgeon and his 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. Appointment Cancellation & No-Show Policy The policy of this office is to require patients to give us notice of cancellation of any appointment within at least 48 hours from the scheduled appointment time. It is further understood that if any patient fails to appear or cancels an appointment without at least 48 hours’ advance notification to this office, the following fees will be applied to your account with reasonable consideration of circumstances, including unforeseen emergencies or sickness. Please note that your insurance will not reimburse you for these fees. Appointments with a ½ hour block --------$100.00 Appointments with a 1 hour block ---------$150.00 Appointments with a 1 ½ hour block ------$300.00 Appointments with a 2 hour block ---------$500.00 This is a non-refundable charge and no further appointments will be made without the patient’s portion of the surgery being paid in full. The applied cancellation charge must also be paid at the time of rescheduling. If the appointment is cancelled within the 48 hours, the surgery fee will be reimbursed.