Section 1 of 8 in this document

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PATIENT REGISTRATION

Name of Patient *

Date *

Gender

Female

Male

Date of Birth *

Age

Social Security Number

Email *

Home Address *

City *

State *

Zip *

Home Phone

Business Phone

Mobile Phone *

Dentist

Medical Doctor

Referred By

Drivers License Number

Nearest Relative

Phone

Have you ever been a patient of our practice?

Yes

Have any of your friends or family been patients at our office before?

Yes

Payment Method

Cash

Check

Credit Card

Section 2 of 8 in this document

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Person Responsible

Who Will Be Responsible For Your Account? (if Self, skip to the next section)

Self

Spouse

Father

Mother

Other

Name

Social Security Number or ID Number

Phone

Home Address

City

State

Zip

Employer

Phone

Spouse or other guarantor information (if different from above)

Name

Social Security Number or ID

Phone

Home Address

City

State

Zip

Employer

Phone

Patient Information

Student

Full-Time

Part-Time

School Name

Marital Status

Married

Divorced

Legally Separated

Widow

Single

Employed

Full-Time

Part-Time

Retored

Not Employed

Do you belong to a PPO or HMO?

Yes

Section 3 of 8 in this document

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Dental Insurance

Primary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Medical Insurance

Primary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Dental Insurance

Secondary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Medical Insurance

Secondary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Section 4 of 8 in this document

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HEALTH HISTORY

To our patients: Oral surgeons primarily treat the area in and around your face and mouth. These are part of your entire body, and 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.

Reason for today's office visit *

Height *

Weight *

Are you in good health?

Yes

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

Yes

Are you under the care of a physician?

Yes

If so, when and for what were you treated?

Have you had any illness, operation, or been hospitalized in the past 5 years?

Yes

Do you have unhealed injuries or inflamed areas, growths, or sore spots in or around your mouth?

Yes

If so, please describe where:

Do you have a prosthetic joint/implant?

Yes

If so, please describe where:

Section 5 of 8 in this document

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Have you had, or do you currently have any, of the following?

Have you had a heart valve replacement or vascular graft?

Yes

Do you have a history of TMJ (jaw joint) problems?

Yes

Rheumatic fever?

Yes

Damaged heart valves/mitralvalve prolapse?

Yes

Heart murmur?

Yes

High blood pressure?

Yes

Chest pain, angina?

Yes

Heart attack(s)?

Yes

Irregular heart beat?

Yes

Cardiac pacemaker?

Yes

Heart surgery?

Yes

Bronchitis, chronic cough?

Yes

Asthma?

Yes

Hay fever/sinus problems?

Yes

Tuberculosis?

Yes

Emphysema?

Yes

Difficult breathing/other lung trouble?

Yes

Do you smoke?

Yes

Blood transfusion?

Yes

Blood disorder, such as anemia?

Yes

Bruise easily?

Yes

Bleeding tendency (abnormal bleed)?

Yes

Jaundice, hepatitis, or liver disease?

Yes

Infectious mononucleosis?

Yes

Gallbladder trouble?

Yes

Fainting spells?

Yes

Convulsions, epilepsy?

Yes

Stroke?

Yes

Thyroid trouble?

Yes

Diabetes?

Yes

Low blood sugar?

Yes

Low Blood Pressure?

Yes

Kidney trouble?

Yes

Are you on dialysis?

Yes

Swollen ankles, arthritis or joint disease?

Yes

Stomach ulcers?

Yes

Contagious diseases?

Yes

Sexually transmitted diseases?

Yes

Problems with the immune system?

Yes

Delay in healing?

Yes

A tumor or growth?

Yes

X-ray treatment/chemotherapy?

Yes

Chronic fatigue/night sweats?

Yes

Are you on a diet?

Yes

A history of drug abuse?

Yes

A history of alcohol abuse?

Yes

Contact lenses?

Yes

Eye disease/glaucoma?

Yes

Mental health problems?

Yes

A removable dental appliance?

Yes

Pain and clicking of jaws when eating?

Yes

Malignant hyperthermia?

Yes

Have you had, or do you currently have any, of the items above?

Not Applicable

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

Yes

Who is driving you home? *

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MEDICATION

Any kind of medicine, drugs, or pills?

Yes

Notes

Blood thinners (e.g., Coumadin®, Plavix®, aspirin, or Advil®)?

Yes

Notes

Diet pills (now or in the past)?

Yes

Notes

Tranquilizers?

yes

Notes

Bisphosphonate medications (now or in the past) (e.g., Fosamax®, Zomeda®, Actonel®)?

Yes

Notes

Any kind of natural product, herbal supplement, or homeopathic remedy?

Yes

Notes

Please list all medications you are currently taking:

Medication 1 *

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

ALLERGIES

Local anesthetics?

Yes

Notes

Penicillin?

Yes

Notes

Other antibiotics?

Yes

Notes

Sodium Pentothal, propofol, Valium®, or other tranquilizers?

Yes

Notes

Aspirin/ibuprofen?

Yes

Notes

Codeine or other narcotics?

Yes

Notes

Other medications?

Yes

Notes

Latex?

Yes

Notes

Sulfites, soy products, or eggs?

Yes

Notes

Please list any allergies other than above:

WOMEN ONLY

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

Is there a possibility of pregnancy?

Yes

Are you nursing?

Yes

Estimated delivery date?

Are you taking birth control pills?

Yes

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

Yes

Do you wish to speak to the doctor privately about anything?

Yes

Is there a family history of (check if applies):

Cancer

Diabetes

Heart Disease

Anesthetic Problems

Not Applicable

IN CASE OF EMERGENCY, CONTACT:

Name *

Phone *

Work Phone

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

Patient Name

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FEES AND PAYMENTS

We make every effort to keep down the cost of your oral surgical 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 fee 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, attorney’s fees, and court costs.

Patient Name

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.

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.

Reviewed By

Signature of Doctor

Date

Signature of Witness

Date

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Notice of Privacy Practices for the offices of Muir Oral, Facial, & Dental Implant Surgery. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Notice of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility. Muir Oral, Facial, & Dental Implant Surgery reserves the right to change the privacy practices currently described in the Notice of Privacy Practices. If Privacy Practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a Notice of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowance disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO.” Without indicating “YES” in answer to each individual question, personal protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse only

Yes

Any member of my immediate family (spouse, children, children's spouses)

Yes

Any member of my extended family (parents, grandchildren)

Yes

Other

Name of Patient

Patient's Personal Representative:

Personal Representative's Phone #:

Date

Signature of doctor

Signature of witness

witness signed date

doctor signed date

Mobile Users

Rotate your phone screen on the signature page to click the submit button.

Have you ever been a patient of our practice?

Yes

Have any of your friends or family been patients?

Yes

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Document Signers

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