Wichita Oral Surgery - Patient Form

First Name

Last Name

Patients Relationship to Subscriber

Insured Party Gender

Date of birth

Insurance Company Name

Member ID

Group Number

First Name

Last Name

Patients Relationship to Subscriber

Insured Party Gender

Date of birth

Insurance Company Name

Member ID

Group Number

Do you have secondary dental or medical insurance?

What is your reason for visiting our practice?

What is your height? (ft & in.)

What is your weight? (lbs.)

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

Do you have a prosthetic joint/implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia or deep sedation?

Have you had any unusual or serious reactions to general anesthesia?

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

Who is driving you home?

Mobile Phone

Relation

Preferred Pharmacy

*Rheumatic fever

*Damaged heart valves/mitral valve prolapse

*Heart murmur

*High blood pressure

*Chest pain/ angina

*Heart attack(s)

*Irregular heart beat

*Cardiac pacemaker

*Heart surgery

*Pneumonia, bronchitis or chronic cough

*Asthma

*Snoring

*Sleep Apnea / CPAP

*Do you smoke or vape?

*Blood disorder such as anemia

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Kidney trouble

*High cholesterol

*Are you on dialysis?

*Osteoporosis/ osteopenia

*Osteonecrosis

*Problems with the immune system? Possibly from medication/ surgery, etc.

*Cancer, radiation therapy or chemotherapy

*A history of alcohol abuse

*A history of drug use?

*Pain and clicking of jaws when eating

Are you pregnant?

Are you nursing?

Do you take any medications, drugs or pills? (If yes, please list ALL medications you are currently taking)

I hereby acknowledge and authorize that I have read and understood all the questions above. I will not hold the doctor, or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form. I authorize my surgeon and his staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and the 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 other doctors and/or insurance carriers. I permit messages to be left for me concerning my appointment(s). 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.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

We make every effort to keep down the cost of your care. 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.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.