DSNForms

Glacier Oral & Maxillofacial Surgery - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Dentist Name

First Name

Last Name

Who were you referred by?

First Name

Last Name

Preferred Pharmacy Name

Preferred Pharmacy Phone

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Guarantor Information

Who will be responsible for your account?

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Primary Dental Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Dental Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Insurance Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Do you have secondary dental insurance?

Health history

Clinical Documentation Notice

As part of our documentation process, conversations during your appointment(s) may be audio recorded and securely transcribed using HIPAA-compliant technology to assist with the preparation of your clinical notes and medical record.

To our patients: Although oral and maxillofacial surgeons primarily treat the area in face and mouth, these areas are a part of your entire body. Your health conditions or medications 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.

What is your reason for visiting our practice?

What is your height? (in.)

What is your weight? (lbs.)

Are you in good health?

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

Are you under the care of a physician?

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

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

Do you have a prosthetic joint/implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia?

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

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

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

Is there a FAMILY history of

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

Health History Cont.
Have you had or do you currently have...

Select all that apply to YOU

Rheumatic fever

Damaged heart valves/mitral valve prolapse

Heart murmur

High blood pressure

*Low blood pressure

Chest pain/ angina

Heart attack(s)

Irregular heart beat

Cardiac pacemaker

Heart surgery

Pneumonia, bronchitis or chronic cough

Asthma

Hay fever/sinus problems

Snoring

Sleep Apnea / CPAP

Difficult breathing/other lung trouble

Tuberculosis

Emphysema

Do you smoke or vape?

Do you use marijuana?

Do you use chewing tobacco?

Blood transfusion

Blood disorder such as anemia

Bruise easily

Bleeding tendency/ abnormal bleed

Hepatitis, jaundice, or liver disease

Infectious mononucleosis

Gallbladder trouble

HIV/AIDS

Have you had or do you currently have...

Fainting spells

Convulsions/ epilepsy

Stroke

Thyroid trouble

Diabetes

Low blood sugar

Kidney trouble

High cholesterol

Are you on dialysis?

Swollen ankles, arthritis or joint disease

Osteoporosis/ osteopenia

Osteonecrosis

Stomach ulcers/ acid reflux

Contagious diseases

Sexually transmitted disease

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

Delay in healing

A tumor or growth

Cancer, radiation therapy or chemotherapy

Chronic fatigue/ night sweats

Are you on a diet?

A history of alcohol abuse

A history of drug use?

Contact lenses

Eye disease/ glaucoma

Mental health problems/ anxiety/ depression

Removable dental appliance

Pain and clicking of jaws when eating

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Note: Antibiotics may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

List of Medications Taken

Are you taking any kind of medication, drug, pills?

Medications (Are you now taking...)

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

Have you ever taken diet pills

If yes, please describe

Any natural product, herbal supplement or homeopathic remedy

If yes, please describe

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?

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone

Suboxone

Oxycodone

Fentanyl

Other

Other Description

Treating Doctor First Name

Treating Doctor Last Name

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

If yes, describe reaction:

Penicillin

If yes, describe reaction:

Sulfa Drugs

If yes, describe reaction:

Sodium pentothal, Valium, or other tranquilizer

If yes, describe reaction:

Aspirin

If yes, describe reaction:

Codeine or other narcotics

If yes, describe reaction:

Latex

If yes, describe reaction:

Other antibiotics

Do you have any known allergies?

Please list any other medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Patient Screening Form

PRE APPOINTMENT

IN OFFICE

Do you/they have fever or have you/they felt hot or feverish recently?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your/their age over 60?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

I fully understand and agree, according to state regulations, that I will contact the office if I develop any of the symptoms above within seven days visiting and / or being treated by this office
Verification

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.

*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.

FEES & PAYMENTS

We make every effort to keep down the cost of your care. We are a fee for service practice, so you can help by paying before each visit. Other arrangements can be made with our office 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 these forms. Please remember that insurance is considered a method of reimbursing the patient for fees paid to Glacier OMS and is not a substitute for payment. Some insurance companies pay fixed allowances for certain procedures and others pay a percentage of the charge. We are a fee for service practice, so it is your responsibility to ensure insurance reimbursements are accurate and complete. 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.

Release of Information

This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to PT.

*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.

Authorization for Service

I authorize my surgeon and their designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all radiographs / 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.

*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.

Notice of Privacy Practices

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices is 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.