Please fill out the registration form to the best of your knowledge. All patient information is confidential P A T I E N T   Patient First Name: M.I. Patient Last Name: Sex: male female Date of Birth (MM/DD/YY): Age: Social Security: Street: City State: Zip Home Tel: Bus. Tel: Ext. Dentist: Orthodontist: Physician: Referred By: Have you ever been a patient in our practice: Yes No Method of Personal Payment: Cash Check Credit Card A C C O U N T   Who will be responsible for your account? Self Spouse Father Mother Other Name: Social Security: Home Tel: Street: City State: Zip Employer: Tel: I N S U R A N C E   Student: Full Time Part Time Not School Name School Address Status: Married Divorced Legally Separated Widow Single Employed: Full Time Part Time Retired Not Do you belong to a PPO or HMO? Yes No PRIMARY DENTAL INSURANCE   Employer: Address: Bus. Tel: Insurance Company Name: Address: Phone: Group No.: Group Name: Insured Party: Relation: Sex: MF Date of Birth (MM/DD/YY): Street: City: State: Zip Phone: Social Security: ID No.: PRIMARY MEDICAL INSURANCE   Employer: Address: Bus. Tel: Insurance Company Name: Address: Phone: Group No.: Group Name: Insured Party: Relation: Sex: MF Date of Birth (MM/DD/YY): Street: City: State: Zip Phone: Social Security: ID No.: SECONDARY DENTAL INSURANCE   Employer: Address: Bus. Tel: Insurance Company Name: Address: Phone: Group No.: Group Name: Insured Party: Relation: Sex: MF Date of Birth (MM/DD/YY): Street: City: State: Zip Phone: Social Security: ID No.: SECONDARY MEDICAL INSURANCE   Employer: Address: Bus. Tel: Insurance Company Name: Address: Phone: Group No.: Group Name: Insured Party: Relation: Sex: MF Date of Birth (MM/DD/YY): Street: City: State: Zip Phone: Social Security: ID No.: Please fill out the health history to the best of your knowledge All patient information is confidential 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. Reason for today's visit: YES NO Are you in good health: Height: Weight: Have there been any changes in your general health in the past year? Are you under the care of a physician? Date of last visit: If so, for what are you being treated? Have you had any illness, operation or been hospitalized in the past five years? Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? If so describe where: Do you have a prosthetic joint? If so describe where: Do you have a vascular graft? If so describe where: Have You Had or Do You Currently Have Yes No Have You Had or Do You Currently Have Yes No Rheumatic fever? Stroke? Damaged heart valves/ mitral valve prolapse? Thyroid trouble? Heart murmur? Diabetes? High blood pressure? Low blood sugar? Low blood pressure? Kidney trouble? Chest pain, angina? Are you on dialysis? Heart attack(s)? Swollen ankles, arthritis or joint disease? Irregular heart beat? Stomach ulcers? Cardiac pacemaker? Contagious diseases? Heart surgery? Sexually transmitted diseases? Bronchitis, chronic cough? Problems with the immune system? Asthma? Delay in healing? Hay fever / Sinus problems? A tumor or growth? Tuberculosis? X-Ray treatment / chemotherapy? Emphysema? Chronic fatigue / night sweats? Difficult breathing / other lung trouble? Are you on a diet? Do you smoke? A history of drug abuse? Blood transfusion? A history of alcohol abuse? Blood disorder such as anemia? Contact lenses? Bruise easily? Eye disease / glaucoma? Bleeding tendency (abnormal bleed?) Mental health problems? Jaundice, hepatitis or liver disease? A removable dental appliance? Infectious mononucleosis? Pain & Clicking of jaws when eating? Gallbladder trouble? Malignant Hyperthermia? Fainting spells? Have you had anything to eat or drink in the last 8 hours? Convulsions, epilepsy? Who is driving you home today? | Welcome | Patient Information | Dental Implants | Wisdom Teeth | TMJ | Orthognathic Surgery | | Oral Pathology | Meet The Doctors | On-Line Patient Registration | On-Line Referral Form | E-Mail | | Post-Operative Instructions | Map | Visit Our Office | This web site is designed by OMSNet®, a subsidiary of PBHS, Inc. ©1997.