** - Patient Form

General Insurance information

Employed

Marital status

Are you a student?

School Name

Do you have secondary dental or medical insurance?

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. 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.

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?

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?

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

Is there a possibility of pregnancy?

Are you nursing?

Are you taking birth control pills?

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

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

Have you ever taken diet pills

Any natural product, herbal supplement or homeopathic remedy

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

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Sodium pentothal, Valium, or other tranquilizer

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Sulfites

Do you have any known allergies?

Please list any allergies other than drug allergies?

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

Is this related to an accident?

If Yes, What type?

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone

I certify that the information I have provided is true and complete to the best of my knowledge. I understand that I am responsible for notifying the office of any changes to my medical or personal information. I will not hold my doctor or staff responsible for errors or omissions resulting from inaccurate or incomplete information I have provided.

Payment is due at the time services are rendered unless prior arrangements have been made. As a courtesy, we will assist in filing dental insurance claims; however, insurance is a contract between you and your carrier and is not a substitute for payment. You are responsible for all deductibles, co-insurance, and any balance not paid by your insurance. If an account is placed for collection, you agree to be responsible for all costs of collection, including reasonable attorney fees and court costs, to the extent permitted by law.

I authorize the release of any medical or other information necessary to process my dental insurance claims, including protected health information as permitted by applicable privacy laws.

I authorize my surgeon and designated staff to perform an oral and maxillofacial examination for diagnosis and treatment planning, including any necessary radiographs (x-rays) and/or CBCT imaging. I authorize the release of information for coordination of care and insurance processing. I consent to receive communications from the office, including appointment reminders, via phone (including voicemail), mobile phone, and/or email using the contact information I have provided.

I acknowledge that I have been offered a copy of Lone Star Oral & Facial Surgery’s Notice of Privacy Practices, which is available for review and download on the Patient Information page at www.lonestaroralfacial.com. I understand how my health information may be used and disclosed, and I have been given the opportunity to ask questions.

By signing below, I acknowledge that I have read, understand, and agree to all the above policies and authorizations. I further acknowledge and agree that this signature constitutes my legal signature and may be used as my electronic signature for all documents, including legally binding documents, with the same force and effect as a handwritten signature.

*Sign

*Date