DSNForms
*First Name
Middle Name
*Last Name
Nickname
*Date of birth
*Sex Assigned at Birth
Preferred Pronoun
Social Security Number
Street Address 1
Apt.
State
Zip
City
Primary Phone
Alternate Phone (Mobile, work, or home)
Email
Occupation
Employer
Preferred Pharmacy & Phone Number
First Name
Last Name
Relationship to Patient
Date of birth
Relative Phone
Address ( If Different from Patient )
Home Phone
Mobile Phone
Ins. Company Name
Policy I.D. Number
Group Number
Subscriber Name
Subscriber Date of Birth
Relationship To Patient
Do you have secondary dental or medical insurance?
Employer / Business
Referring Dentist / Physician
Referring Office Phone
What is your reason for visiting our practice?
Tooth/Teeth or Area Involved
How long has this been a concern?
Are you in pain today?
What is your height? (in.)
What is your weight? (lbs.)
Primary Care Physician
Physician Phone
Date of Last Physical Exam
Heart Disease, Hx Heart Surgery
High Blood Pressure
Artificial Heart Valve
Cardiac pacemaker
History of Heart attack(s)
Heart Arrythmia of AFIB
Bleeding / Clotting Disorder
COPD/Emphysema
Stroke / TIA
Thyroid Disorder
Asthma
Sleep Apnea
Kidney Disease
Liver Disease
Infectious Disease (HIV, Hep C)
Autoimmune Disease
Seizures / Epilepsy
Anxiety / Panic Disorder
Osteoporosis
Bisphosphonate Use
Cancer / Chemotherapy
Radiation Therapy (Head/Neck)
Pregnant / Possibly Pregnant
GERD
Current GLP-1 Use
Hx of Gastric Bypass Surgery
Diabetes (Type 1 or 2)
Are you taking any kind of medication, drug, pills?
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Do you have any known allergies?
Reactions to Anesthesia (Local or General) In The Past?
Known Anxiety or PTSD Triggers?
Do You Smoke or Vape
Recreational Drug Use?
Family History of Anesthesia Complications
ACKNOWLEDGEMENT
I certify that the information given in this form is accurate to the best of my knowledge. I will inform this office of any changes in my medical status prior to my procedure.
Dental/medical insurance is a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. I understand that I am fully responsible for paying any deductible amount, co-insurance, and other obligations not paid for by my insurance.
*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.
I authorize my oral surgeon and his designated staff to perform an oral and maxillofacial examination for diagnosis and treatment planning. Furthermore, I authorize the taking of all required X-rays as part of the examination.
I am authorizing the release of any information pertaining to the examination, and treatment to my other doctors and insurance companies by phone, email, and mail.
This office maintains a Notice of Privacy Practices describing how your medical and dental information may be used and disclosed, and how you can access that information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA). A copy is available at the front desk and on our website upon request.
I acknowledge that I have received, or been offered, a copy of this office's Notice of Privacy Practices.
I authorize this office to leave detailed messages regarding my appointments, treatment, and billing at the phone number(s) and/or email provided above.
I authorize this office to discuss my protected health information with the following individual(s) (name and relationship, if any)
Date