DSNForms

Central Virginia Oral and Facial Surgeons - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

*Sex assigned at birth

Preferred Pronouns

*Street Address

Street Address 2

*City

*State

*Zip

Email

*Mobile Phone (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

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Primary Medical Insurance

Subscriber Information

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Policy Holder's Address

City

State

Zip

Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Group Number

Primary Dental Insurance

Subscriber Information

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Policy Holder's Address

City

State

Zip

Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Group Number

Do you have secondary 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?

*Do you use chewing tobacco?

*Stent placement

*Blood disorder such as anemia

*Bruise easily

*Bleeding disorder (Hemophilia, Von Willebrand)

*Hepatitis, jaundice, cirrhosis or liver disease

*Infectious mononucleosis

*Other heart defect

*HIV/AIDS

-

*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

*Contagious diseases

*Sexually transmitted disease

*Problems with the immune system

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Chronic fatigue/ night sweats

*Other heart defect

*Alcohol Use

*A history of substance use disorder

*Acid reflux/GERD

*Eye disease/ glaucoma

*Mental health condition/ anxiety/ depression

*Removable dental appliance

*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 breastfeeding?

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.

*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 drug addiction please select the medication you are currently taking:

Do you have a pain contract?

Pain Doctor First Name

Pain Doctor Last Name

Allergies

*Do you have any known allergies?

Please list any medication allergies

Medication / Antibiotic Allergy #1

Medication Name

Please list any other allergies you may have

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

PATIENT VERIFICATION, CONSENT, FINANCIAL RESPONSIBILITY & ACKNOWLEDGMENTS

I certify that the information I have provided in this registration form is true, correct, and complete to the best of my knowledge. I understand that any errors or omissions may affect my care, and I will not hold the doctor or staff responsible for inaccuracies I have provided.

I authorize my surgeon and designated staff to perform an oral and maxillofacial examination, including diagnostic procedures and necessary radiographs, for purposes of diagnosis and treatment planning. I authorize the release of information obtained during my examination and treatment to other healthcare providers and/or insurance carriers as medically necessary.

I authorize this office to release information necessary to process insurance claims and request payment of benefits. I understand that insurance is a method of reimbursing the patient and is not a substitute for payment. I agree that I am financially responsible for all charges incurred, including deductibles, co-insurance, balances not paid by insurance, and, if applicable, collection costs, attorney’s fees, and court costs.

I acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me, and I have had the opportunity to ask questions regarding its contents.

I consent to receive appointment-related communications, including messages left on voicemail and/or mobile devices.

By signing below, I acknowledge that I have read, understand, and agree to all sections of this patient registration form. I agree that my signature, whether written or electronic, serves as my legally binding signature for all documents and authorizations within this office, with the same effect as a pen-and-paper signature.

*Please print your name

*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.