Rochester Periodontics - Patient Form

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

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?

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?

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

*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 general anesthesia?

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

*Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

*Is there any condition concerning your health that the doctor should be told about?

*Do you wish to speak to the doctor privately about anything?

*If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

*Cancer

*Diabetes

*Heart Disease

*Anesthesia Problems

*Autism

*A history of alcohol abuse

*A history of drug use?

*A tumor or growth

*Are you on a diet?

*Are you on dialysis?

*Asthma

*Bleeding tendency/ abnormal bleed

*Blood disorder such as anemia

*Blood transfusion

*Bruise easily

*Cancer, radiation therapy or chemotherapy

*Cardiac pacemaker

*Chest pain/ angina

*Chronic fatigue/ night sweats

*Contagious diseases

*Contact lenses

*Convulsions/ epilepsy

*Damaged heart valves/mitral valve prolapse

*Delay in healing

*Diabetes

*Difficult breathing/other lung trouble

*Do you smoke or vape?

*Do you use chewing tobacco?

*Do you use marijuana?

*Emphysema

*Eye disease/ glaucoma

*Fainting spells

*Gallbladder trouble

*Hay fever/sinus problems

*Heart attack(s)

*Heart murmur

*Heart surgery

*Hepatitis, jaundice, or liver disease

*High blood pressure

*High cholesterol

*HIV/AIDS

*Infectious mononucleosis

*Irregular heart beat

*Kidney trouble

*Low blood pressure

*Low blood sugar

*Mental health problems/ anxiety/ depression

*Osteonecrosis

*Osteoporosis/ osteopenia

*Pain and clicking of jaws when eating

*Pneumonia, bronchitis or chronic cough

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

*Removable dental appliance

*Rheumatic fever

*Sexually transmitted disease

*Sleep Apnea / CPAP

*Snoring

*Stomach ulcers/ acid reflux

*Stroke

*Swollen ankles, arthritis or joint disease

*Thyroid trouble

*Tuberculosis

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

*Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

*Have you ever taken diet pills

*Any natural product, herbal supplement or homeopathic remedy

*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?

*Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

*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:

*Methadone

*Suboxone

*Oxycodone

*Fentanyl

*Other

Other Description

Treating Doctor First Name

Treating Doctor Last Name

*Local anesthetic (numbing medication)

*Penicillin

*Other antibiotics

*Sulfa Drugs

*Sodium pentothal, Valium, or other tranquilizer

*Aspirin

*Amoxicillin

*Codeine or other narcotics

*Latex

*Soy

*Eggs/Yolk

*Sulfites

*Do you have any known allergies?

Please list any allergies other than drug allergies?

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

*First Name

*Last Name

Home Phone

*Mobile Phone

*Relationship to Patient

*Is this related to an accident?

If Yes, What type?

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone

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.

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. 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 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.

I authorize my surgeon and 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.

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.