The San Diego Center for Oral Maxillofacial Surgery - Patient Form

*Prefix

*First Name

Middle Name

*Last Name

*Gender

*Date of birth

Social Security Number

Email

Street Address 1

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

Referred by

Referred by Telephone number

Dentist

Dentist Phone

Medical Doctor

Medical Doctor Phone

Employer

Employer Phone

In case of an emergency, Please contact

emergency contact phone

Relation

Are you a student?

Marital status

Employed

School Name and Address

Plan Name

Ins. Company Name

Policy I.D. Number

Plan Name

Ins. Company Name

Policy I.D. Number

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

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

Do you have secondary dental or medical insurance?

Are you in good health?

What is your height? (in.)

What is your weight? (lbs.)

Are you under the care of a phyisician?

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

*Rheumatic fever

*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

*Chronic fatigue/ night sweats

Trouble climbing 1-2 flights of stairs

*Mental health problems/ anxiety/ depression

Damaged heart valves

*Asthma

Are you immunosuppressed? (possibly from transplant surg.)

*Hay fever/sinus problems

*Snoring

*Sleep Apnea / CPAP

Respiratory problems

*Tuberculosis

*Emphysema

*Do you smoke or vape?

*Do you use chewing tobacco?

*Blood transfusion

*Blood disorder such as anemia

*Bruise easily

*A history of drug use?

*Eye disease/ glaucoma

*Bleeding tendency/ abnormal bleed

Problems w/ immune system? ( Possibly from med. / surg. )

*Hepatitis, jaundice, or liver disease

*Gallbladder trouble

*Fainting spells

*Infectious mononucleosis

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*A history of alcohol abuse

*Sexually transmitted disease

*Swollen ankles, arthritis or joint disease

Low blood sugar

*Kidney trouble

*Are you on dialysis?

*Osteoporosis/ osteopenia

*Osteonecrosis

*High cholesterol

*Stomach ulcers/ acid reflux

*Contagious diseases

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Are you on a diet?

*Contact lenses

*Immune system problems

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

Nerve pills

Have you ever taken diet pills

Blood thinners (Coumadin, Aspirin, Advil)

Any bone density medications or Bisphosphonates (Aredia, Zometa, Fosamax, Actonel)

Pain killers (including aspirin)

Tranquilizers

Muscle relaxers

Insulin

Antidepressants

Stimulants

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Penicillin

Valium or other tranquilizers

Soy

Sulfa Drugs

Aspirin

Eggs/Yolk

Local anesthetic (numbing medication)

Codeine or other narcotics

Sulfites

Sodium pentothal, Valium, or other tranquilizer

Latex

Amoxicillin

Please list any allergies other than drug allergies?

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

1-4 below for women only: (Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.)

1) Is there a possibility of pregnancy?

2) Expected delivery date:

3) Are you nursing?

4) Are you taking birth control pills:

I authorize my surgeon and his/her staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. I authorize the taking of all x-rays required as a necessary part of this examination. I also authorize the release of any information acquired in the course of my examination and treatment, if medically necessary and if needed to process my claim. This signature on file is my authorization for the release of any information for the above purposes.

Please understand 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 by your insurance company. You will be responsible for all collection costs. I hereby authorize payment to this doctor named of the benefits otherwise payable to me

A $20.00 fee will be charged for appointments that are cancelled without 5 business days notice. If a surgical appointment is cancelled without at least 5 business days notice, whether scheduled in the hospital or our office, the patient’s account will be charged 10% of the total procedure charges

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 the Notice

I certify that I have read and understand this document in its entirety. I acknowledge that my questions if any, about the inquires set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Signature of patient (Parent or Guardian if minor)

Date

Print name

Date

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