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New Patient Registration Fields marked with * are required

First Name *

Last Name *

Preferred Name

Gender * Male Female

Date Of Birth *

Driver's License Number *

SSN *

Address *

Address (optional)

City *

State *

Zip *

Primary Phone *

Email *

Have you ever been a patient of our practice? * Yes No

Has a family member ever been a patient of our practice? * Yes No

Employer *

Business Number *

Personal Payment Type *

Referred By Fields marked with * are required

Referred By *

Dentist *

Orthodontist *

Medical Dr. *

Emergency Contact Fields marked with * are required

Nearest relative not living with you *

Phone Number *

In case of emergency, please contact *

Relation *

Phone Number *

Responsible Party Fields marked with * are required

Who will be responsible for your account? * Self (if self: skip this section) Spouse Father Mother

If other, describe

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

City

State

Zip

Primary Phone

Employer

Phone NUmber

Student Status Fields marked with * are required

Are you currently a student? * Yes No

What school name?

Address

City

State

Zip Code

Marital Status / Employed Fields marked with * are required

What is your marital status? *

What is your employment status? *

If other above, do you belong to a PPO or HMO? *

Primary Dental Insurance Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Preferred Name

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Secondary Dental Insurance Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Preferred Name

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Health History Fields marked with * are required

To Our Patients Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of the entire body. Health problems that you may have, or medications 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 office visit? *

Height *

Weight *

Are you in good health? * Yes No

Are you currently being treated by a physician? * Yes No

If so, for what are you being treated?

Have you had any illness, operation or been hospitalized in the past five years? * Yes No

If so, describe

Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth? * Yes No

If so, describe where

Do you have a prosthetic joint / implant? * Yes No

If so, describe where

Have you had a heart valve replacement or vascular graft? * Yes No

If so, describe

Have you ever had general anesthesia? * Yes No

If so, describe

Have you, or a family member, had any unusual or serious reactions to general anesthesia? * Yes No

If so, describe

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? * Yes No

If so, describe

Do you have Osteoporosis or Osteopenia? * Yes No

If so, describe

Do you have a Sexually Transmitted Disease? * Yes No

If so, describe

Do you have Osteonecrosis * Yes No

If so, describe

Do you have Stomach Ulcers/Acid Reflux? * Yes No

If so, describe

Do you have any contagious diseases? * Yes No

If so, describe

Do you have problems with immune system/possible from medication/surgery, etc * Yes No

If so, describe

Do you have delay in healing? * Yes No

If so, describe

Do you have, or have you had, any of the following? Fields marked with * are required

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, chronic cough

Asthma

Hay fever / sinus problems

Snoring

Sleep apnea / CPAP

Difficult breathing / other lung trouble

Tuberculosis

Emphysema

Do you smoke?

If so, number of packs a day? *

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

Fainting spells

Convulsions / epilepsy

Stroke

Thyroid trouble

Cancer

If yes, what type? *

Diabetes

Low blood sugar

Kidney trouble

High cholesterol

Are you on dialysis

Swollen ankles/arthritis/joint disease

Stomach ulcers/acid reflux

Problems with immune system? Possible from from medication/surgery, etc?

A tumor or growth

Cancer/radiation therapy/chemotherapy

Chronic fatigue/night sweats

Are you on a diet

History of alcohol abuse

History of drug abuse

Contact lenses

Eye disease/glaucoma

Mental health problems/anxiety/depression

Removeable dental appliance

Pain or clicking in the jaw when eating

Have you ever had any serious illnes not listed? * Yes No

Comments

Women Health History Fields marked with * are required

Are you a woman? * Yes No

Are you pregnant? Yes No

If yes, expected delivery date?

Are you nursing? Yes No

Are you taking birth control pills? Yes No

Medications Fields marked with * are required

Any kind of medication, drug, pills * Yes No

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil) * Yes No

Have you ever taken diet pills? * Yes No

Any natural product, herbal supplement or homeopathic remedy? * Yes No

Are you taking, or have you ever taken, bone density meds. or bisphosponates such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or Reclast in the past 12 years? * Yes No

Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? * Yes No

If so, please list:

Please list any medications you are currently taking:

If you are having surgery TODAY, have you had anything to eat or drink in the last 6(six) hours? * Yes No

Who is driving you home? *

Is there any condition concerning your health that the Doctor should be told about? * Yes No

If yes, describe

Do you wish to speak to the Dr. privately about anything? * Yes No

Are you allergic to any of the following? Fields marked with * are required

Local anesthetic (numbing meds.) * Yes No

Penicillin * Yes No

Other antibiotics * Yes No

Sulfa drugs * Yes No

Sodium pentothal / Valium / Other tranquilizers * Yes No

Aspirin * Yes No

Amoxicillin * Yes No

Codeine or other narcotics * Yes No

Latex * Yes No

Soy * Yes No

Eggs / yolk * Yes No

Sulfites * Yes No

Do you have any known allergies? * Yes No

Please list any allergies

Is There a Family History of: Fields marked with * are required

Diabetes * Yes No

Heart Disease * Yes No

Cancer * Yes No

High Blood Pressure * Yes No

Accident Fields marked with * are required

Is this visit related to an accident? * Yes No

If yes, what type of accident? (Automobile, work related, other)

Date of injury

Insurance company handling the claim

Claim number

Name of attorney / adjustor

Phone number

Terms And Conditions Fields marked with * are required

Authorizations * I CERTIFY that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquires 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.

Insurance and Payment * 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 other 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.

Payment *

Treatment Authorization *

Release Authorization Fields marked with * are required

I authorize PRACTICE NAME to release my medical and/or billing information to the following individuals:

HIPAA and Privacy Practices Consent Fields marked with * are required

HIPAA Consent * I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Signature Fields marked with * are required

Date: 10/17/2025

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