New Patient Registration Form

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Patient Information

Prefix

Mr.

Mrs.

Ms.

Dr.

Name(Required)

First Name M. I. Last Name Nickname

Sex(Required)

Male

Female

Birthdate(Required)

Age(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Tel

Cell #(Required)

Have you ever been a patient of our practice?(Required)

Yes

Dentist

First Last

Medical Doctor

First Last

Referred By

First Last

Driver's Lic. #

Nearest relative not living with you

First Last

Tel.

Employer

Bus. Tel.

Who will be responsible for your account?(Required)

Self

Spouse

Father

Mother

Other

Who will be responsible for your account?

Name

First Last

Birthdate

Age

Tel

Address

Street Address City State / Province / Region ZIP / Postal Code

Employer

Bus. Tel.

Spouse or other guarantor information (if different from above)

Name

First Last

Relation

Birthdate

Address

Street Address City State / Province / Region ZIP / Postal Code

Tel

Employer

Bus. Tel.

INSURANCE INFORMATION

Student(Required)

Full Time

Part Time

Not

Status(Required)

Married

Divorced

Legally Separated

Widow

Single

Employed(Required)

Full Time

Part Time

Retired

Not

School Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you belong to PPO or HMO?

Yes

Primary Dental Insurance Company

Employer

Insurance Company Name

Address

Group #

Tel

Policy #

Insured Policy Holder

Name Relation

Birthdate

ID #

Primary Medical Insurance Company

Employer

Insurance Company Name

Address

Group #

Tel

Policy #

Insured Policy Holder

Name Relation

Birthdate

ID #

Medication- Are you now taking or have you taken.

Any kind of medication, drug, pills?(Required)

Yes

Blood thinners, (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)?(Required)

Yes

Have you ever taken diet pills?(Required)

Yes

Any natural or herbal product, supplement, or homeopathic remedy?(Required)

Yes

Any bone density medications / Bisphosphonates (Aredia , Zometa , Fosamax, Actonel)?(Required)

Yes

Have you ever taken tranquilizers, sleeping pills, anti-depressants and / or narcotics on a reqular basis ?(Required)

Yes

Have you ever taken tranquilizers, sleeping pills, anti depressants, and / or narcotics on a reqular basis ? if so please list

Please list any medications you are currently taking:(Required)

Allergies - Are you allergic to or have you had a reaction to…

Local anesthetic (numbing med)(Required)

Yes

Penicillin(Required)

Yes

Other Antibiotics(Required)

Yes

Sulfa Drugs(Required)

Yes

Aspirin(Required)

Yes

Sodium Pentothal, Valium, or other tranquilizers(Required)

Yes

Codeine or other narcotics(Required)

Yes

Other Medications(Required)

Yes

Latex(Required)

Yes

Soy(Required)

Yes

Eggs / Yolk(Required)

Yes

Sulfites(Required)

Yes

Please list any allergies other than drug allergies:

To our patients:

Although oral surgeons primarily treat the area in and around your mouth, various health problems and medications can have an important interrelationship with the care you will receive. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Are you in good health?(Required)

Yes

Height(Required)

Weight(Required)

Have there been any changes in your general health in the recent years?(Required)

Yes

Have there been any changes in your general health in the past years?

Are you under the care of a physician?(Required)

Yes

If so, for what are you being treated?

Date of last visit:

Have you had any serious illness, operation, or been hospitalized in the past five years?(Required)

Yes

If so, describe

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?(Required)

Yes

If so, describe where

Do you have a prosthetic joint/implant?(Required)

Yes

If so, describe where

Have you had a heart valve replacement or vascular graft?(Required)

Yes

Have you had or do you currently have...

Rheumatic Fever(Required)

Yes

Damaged heart valves / mitral valve prolapse(Required)

Yes

Heart murmur(Required)

Yes

High Blood Pressure(Required)

Yes

Chest pain / angina(Required)

Yes

Heart attack(s)(Required)

Yes

Irregular Heart Beat(Required)

Yes

Cardiac Pacemaker(Required)

Yes

Heart Surgery(Required)

Yes

COPD, Bronchitis, chronic cough(Required)

Yes

Asthma(Required)

Yes

Hay fever or sinus problems(Required)

Yes

Snoring / sleep apnea(Required)

Yes

Difficult breathing / other lung trouble(Required)

Yes

Tuberculosis(Required)

Yes

Emphysema(Required)

Yes

Do you smoke(Required)

Yes

Do you use chewing tobacco(Required)

Yes

Blood transfusion(Required)

Yes

Blood disorder, such as anemia(Required)

Yes

Bruise easily(Required)

Yes

Bleeding tendency / abnormal bleed(Required)

Yes

Hepatitis, jaundice or liver disease(Required)

Yes

Infectious mononucleosis(Required)

Yes

Gallbladder trouble(Required)

Yes

Fainting spells(Required)

Yes

Convulsion or epilepsy(Required)

Yes

Stroke(Required)

Yes

Thyroid double(Required)

Yes

Diabetes(Required)

Yes

Low blood sugar(Required)

Yes

Kidney trouble(Required)

Yes

Are you in Dialysis(Required)

Yes

Swollen ankles, arhtritis, or joint disease(Required)

Yes

Stomach Ulcers(Required)

Yes

Contagious Diseases(Required)

Yes

Sexually transmitted diseases(Required)

Yes

Are you immunosuppressed, possibly from transplant surgery, etc.(Required)

Yes

Problems with the immune system? Instead of possibly from medication / surgery, etc.(Required)

Yes

Delayed Healing(Required)

Yes

Tumor or growth(Required)

Yes

Radiation Therapy / chemotherapy(Required)

Yes

Chronic fatigue / night sweats(Required)

Yes

Are you on a diet(Required)

Yes

History of drug abuse(Required)

Yes

History of alcohol abuse(Required)

Yes

Contact Lenses(Required)

Yes

Eye disease / glaucoma(Required)

Yes

Mental Health Problems(Required)

Yes

Removable dental appliance(Required)

Yes

Pain and clicking of jaws when eating(Required)

Yes

Malignant hyperthermia(Required)

Yes

IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?(Required)

Yes

Who is driving you home?

Consent(Required)

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 surgeon, or any other members of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature(Required)

New Patient Registration Form