DSNForms

Kerrville Oral & Maxillofacial Surgery - Patient Form

Patient information

Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Email

Marital status

Gender

Street Address

City

State

Zip

Home Phone

Cell Phone

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Dentist Name

Dr. last name

Orthodontist Name

Dr. last name

Physician Name

Dr. last name

Guarantor Information (If other than patient)

First Name

Last Name

Relative Phone

Relationship to patient

NOTE: Kerrville OMS does not file Medicare, Medicaid, nor Medical insurance claims

*Do you have 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.)

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Reason

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

Do you have a prosthetic joint/implant/ heart valve replacement or other?

Have you ever had general anesthesia?

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

Health History Cont.
Have you had or do you currently have...

The heart valves replacement

High blood pressure

Chest pain/ angina

Heart attack(s)

Irregular heart beat

Cardiac pacemaker

Heart surgery

Pneumonia, bronchitis or chronic cough

Asthma

Hay fever/sinus problems

COPD

Sleep Apnea / CPAP / Snoring

Difficult breathing/other lung trouble

Tuberculosis

Emphysema

Do you smoke or vape?

Do you use marijuana?

Do you use chewing tobacco?

Blood transfusion

Blood disorder such as anemia

Bruise easily

Bleeding tendency/ abnormal bleed

Hepatitis, jaundice, or liver disease

Infectious mononucleosis

HIV/AIDS

Have you had or do you currently have...

Fainting spells

Convulsions/ epilepsy

Stroke

Thyroid trouble

Diabetes

Low blood sugar

Kidney trouble

Are you on dialysis?

Swollen ankles, arthritis or joint disease

Osteoporosis/ osteopenia

Osteonecrosis

Stomach ulcers/ acid reflux

Contagious diseases

Sexually transmitted disease

Problems with the immune system? Possibly from medication/ surgery, etc.

Delay in healing

A tumor or growth

Cancer, radiation therapy or chemotherapy

A history of alcohol abuse

A history of drug use?

Please explain

Mental health problems/ anxiety/ depression

Removable dental appliance

Pain and clicking of jaws

Is there a possibility of pregnancy?

Pharmacy Information

Preferred Pharmacy Name

Medications / Allergies

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

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin , Amoxicillin

Other antibiotics

Aspirin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Sulfites

Do you have any known allergies?

Please list any food allergies.

Please list any medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Financial Agreement

I understand that payment in full is expected at time of service. Payment arrangements must be discussed prior to treatment.

*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.

INSURANCE PLANS

Dr. Lussier is not a contracted provider for any insurance plans. Payment in full is due at each visit. As a courtesy, Kerrville OMS will file a dental claim on the patient’s behalf. The reimbursement for the services provided would be based on your insurance carrier’s guidelines. Your signature below is your authorization for the release of information required by your insurance carrier to process any claim(s) submitted on you or your dependent’s behalf.

NON-COMPLIANCE MAY RESULT IN A POOR SURGICAL OUTCOME, ADDITIONAL FEES AND/OR SURGERY, AND DISMISSAL FROM THE PRACTICE.

*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 his 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 during my examination and treatment to my other doctors and/or insurance carriers. I permit messages or text messages concerning my appointments to be left on my phone and/or mobile phone.

COMPLIANCE WITH ALL PRE-OPERATIVE AND POST-OPERATIVE INSTRUCTIONS WILL BE IMPORTANT FOR A SUCCESSFUL EXPERIENCE AND SUCCESSFUL SURGERY.

*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.

ACKNOWLEDGEMENT- RECEIPT OF PRIVACY PRACTICE NOTICE

The privacy and protection of your patient information is of the utmost importance to Kerrville OMS. As required by the Federal Health Insurance Portability and Accountability Act (HIPAA) Regulations, a Notice of Privacy Practices must be provided by all healthcare providers to their patients. A copy will be provided upon request. It is available on our website and accompanies the new patient paperwork. Kerrville OMS reserves the right to modify the privacy practices outlined in the notice.

I hereby authorize my medical and dental providers to release my protected health information relevant to my medical/dental history which may influence or benefit my planned surgery at Kerrville OMS.  This authorization allows communication to and from Kerrville OMS via phone, fax, email, or written correspondence.

Name

Relationship

Name

Relationship

*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.