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.

Medications

Have you or are you now taking?

Any kind of medication, drug, pills?

Any kind of medication, drug, pills?

Yes No

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Pradaxa, Fish oil)?

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Pradaxa, Fish oil)?

Yes No

Have you ever taken diet pills?

Have you ever taken diet pills?

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Are you taking or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Are you taking or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Yes No

Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list:

Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list:

Please list any medications you are currently taking:

Medication

Dosage

Frequency

Allergies

Are you Allergic to or had a reaction to:

Local anesthetic (numbing meds.)?

Local anesthetic (numbing meds.)?

Yes No

Penicillin?

Penicillin?

Yes No

Other antibiotics?

Other antibiotics?

Yes No

Sulfa drugs?

Sulfa drugs?

Yes No

Sodium pentothal / Valium /other tranquilizers?

Sodium pentothal / Valium /other tranquilizers?

Yes No

Aspirin?

Aspirin?

Yes No

Amoxicillin?

Amoxicillin?

Yes No

Codeine or other narcotics?

Codeine or other narcotics?

Yes No

Latex?

Latex?

Yes No

Soy?

Soy?

Yes No

Eggs /yolk?

Eggs /yolk?

Yes No

Sulfites?

Sulfites?

Yes No

Do you have any known allergies?

Do you have any known allergies?

Yes No

Please list any allergies other than drug allergies:

Please list any other medication or antibiotic you are allergic to:

Medication / Antibiotic Name

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Yes No

Who is driving you home?

Who is driving you home?

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

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

Yes No

If Yes, describe

If Yes, describe

Do you wish to speak to the Dr. privately about anything?

Do you wish to speak to the Dr. privately about anything?

Yes No

Is there a family history of:

Is there a family history of:

Cancer Diabetes Heart disease Anesthesia problems

Is this visit related to an accident?

Is this visit related to an accident?

Yes No

If Yes, what type of accident?

If Yes, what type of accident?

Automobile Work related Other

Date of injury

Date of injury

Insurance company handling the claim

Insurance company handling the claim

Claim number

Claim number

Name of attorney / adjustor

Name of attorney / adjustor

Telephone number

Telephone number

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

Patient's Signature:

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Reviewed by

Reviewed by

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.

Patient's Signature:

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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.

Patient's Signature:

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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.

Patient's Signature:

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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.

Patient's Signature:

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