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Central Virginia Oral and Facial Surgeons - Central Virginia Oral and Facial Surgeons - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Sex assigned at birth

Preferred Pronouns

*Street Address 1

Street Address 2

Apt.

*City

*State

*Zip

Mobile Phone (This will be utilized to send appt reminder texts)

Home Phone

Work Phone

Dentist Name

*First Name

*Last Name

Orthodontist Name

First Name

Last Name

Medical Doctor 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
Guarantor Information

*Who will be responsible for your account? If not self, please complete the information below.

Personal Payment Type

First Name

Last Name

Guarantor Mobile Phone

Guarantor Email Address

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

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.)

*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 sedation or general anesthesia?

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

Have you had or do you currently have...

*Rheumatic fever

*Damaged heart valves, Stenosis or Prolapse

*Heart murmur

*High blood pressure

*Low blood pressure

*Chest pain/ angina

*Heart attack(s)

*Irregular heart beat

*Cardiac pacemaker/Defibrillator

*Heart surgery

*Pneumonia, bronchitis or chronic cough

*Asthma

*Seasonal allergies/sinus problems

*Snoring

*Sleep Apnea / CPAP

*Difficult breathing/other lung trouble

*Tuberculosis

*COPD: Emphysema/Chronic bronchitis

*Do you smoke or vape?

*Do you use marijuana? If yes, how often?

*Do you use chewing tobacco?

*Blood disorder such as anemia

*Bruise easily

*Bleeding disorder (Hemophilia, Von Willebrand)

*Hepatitis, jaundice, cirrhosis or liver disease

*Infectious mononucleosis

*HIV/AIDS

*Stent Placement

*Other heart defect

*Heart Failure (CHF)

-

*Fainting/Syncope/POTS

*Seizures/ epilepsy

*Stroke or Mini stroke

*Thyroid disease

*Diabetes, if yes please state A1C below

*Low blood sugar

*Kidney disease

*High cholesterol

*Are you on dialysis?

*Arthritis or joint disease

*Osteoporosis

*Osteopenia

*Osteonecrosis

*Stomach ulcers

*Acid reflux/GERD

*Contagious disease

*Sexually transmitted disease

*Problems with the immune system/immunosuppression's?

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Chronic fatigue/ night sweats

*Alcohol Use

If yes, please list how many drinks per day.

*A history of substance use disorder

*Eye disease/ glaucoma

*Mental health condition/ anxiety/ depression

*Pain and clicking of jaws when eating

Surgeries

*Please list any surgeries you have had. If none, type N/A

Pregnancy and Birth Control

*Is there a possibility of pregnancy?

Expected delivery date?

Are you breasfeeding?

Are you using contraceptives?

Date of your last period?

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

Medications Allergies

*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)

*GLP-1 (semaglutide, ozempic, wegovy, trulicity, mounjaro)

*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?

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

Do you have a pain contract?

*Methadone

*Suboxone

*Oxycodone

*Fentanyl

*Other

Other Description

Pain Doctor First Name

Pain Doctor Last Name

Are you allergic or had a reaction to:

*Do you have any known allergies?

Please list any medication allergies

Medication / Antibiotic Allergy #1

Medication Name

Please list any allergies other than drug allergies?

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

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. You can help by paying on time at each visit. 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.

*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 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.

*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 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.