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Midstate Oral Surgery and Implant Center - Midstate Oral Surgery and Implant Center - Patient Form

Patient information

Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

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

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
Nearest relative not living with you

First Name

Last Name

Relative Phone

Personal Payment Type

Who will be responsible for your account?

Other Information

Other Description

First Name

Last Name

Date of birth

Social Security Number

Home Phone

Mobile Phone

Email

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Guarantor Information

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Insurance information

General Insurance information

Employed

Marital status

Are you a student?

School Name

Primary Dental Insurance Subscriber
Primary dental information is required

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

Primary Medical Insurance Subscriber
Primary medical information is required

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

Primary Dental Insurance Information

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

Primary Medical Insurance Information

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 or medical insurance?

Secondary Dental Insurance Subscriber

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

Secondary Medical Insurance Subscriber

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

Secondary Dental Insurance Information

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

Secondary Medical Insurance Information

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

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?

Physician Name

Date of last visit

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

If so, describe

*Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

If so, describe

*Do you have a prosthetic joint/implant?

If so, describe

*Have you had a heart valve replacement or vascular graft?

If so, describe

*Have you ever had general anesthesia?

If so, describe

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

If so, describe

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

If so, describe

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

If so, describe

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

If so, describe

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

Who is driving you home?

Mobile Phone

Notify of Pick-up status via

Is there a FAMILY history of

*Cancer

*Diabetes

*Heart Disease

*Anesthesia Problems

*Autism

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

*Rheumatic fever

*Damaged heart valves/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

*Asthma

*Hay fever/sinus problems

*Snoring

*Sleep Apnea / CPAP

*Difficult breathing/other lung trouble

*Tuberculosis

*Emphysema

*Do you smoke or vape?

If so, how much a day?

*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

*Gallbladder trouble

*HIV/AIDS

Have you had or do you currently have...

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*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

*Chronic fatigue/ night sweats

*Are you on a diet?

*A history of alcohol abuse

*A history of drug use?

*Contact lenses

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Removable dental appliance

*Pain and clicking of jaws when eating

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

Date of your last period?

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.

Medications / Allergies
Medications (Are you now taking...)

*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

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

Are you allergic or had a reaction to:

*Local anesthetic (numbing medication)

*Penicillin

*Other antibiotics

*Sulfa Drugs

*Sodium pentothal, Valium, or other tranquilizers

*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?

Use Comma to add multiple allergies

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

Medication / Antibiotic Allergy #1

Medication Name


Patient Screening Form

*PRE APPOINTMENT

*IN OFFICE

Do you/they have fever or have you/they felt hot or feverish recently?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your/their age over 60?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Accident

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

Verification

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.
FEES & PAYMENTS

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 and/or medical 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.
Release of Information

This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to patient.

*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 her 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.
Notice of Privacy Practices

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.