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Meet the Doctors
Services
Biopsy
Bone Grafting
Dental Implants
Removal of Lesion
Tooth Extraction
Wisdom Teeth Removal
For Patients
New Patient Registration
Financing by Proceed Finance
Financing by Care Credit
Insurance
Contact
Menu
Meet the Doctors
Services
Biopsy
Bone Grafting
Dental Implants
Removal of Lesion
Tooth Extraction
Wisdom Teeth Removal
For Patients
New Patient Registration
Financing by Proceed Finance
Financing by Care Credit
Insurance
Contact
Meet the Doctors
Services
Biopsy
Bone Grafting
Dental Implants
Removal of Lesion
Tooth Extraction
Wisdom Teeth Removal
:
For Patients
New Patient Registration
Financing by Proceed Finance
Financing by Care Credit
Insurance
Contact
Menu
Meet the Doctors
Services
Biopsy
Bone Grafting
Dental Implants
Removal of Lesion
Tooth Extraction
Wisdom Teeth Removal
:
For Patients
New Patient Registration
Financing by Proceed Finance
Financing by Care Credit
Insurance
Contact
(580) 404-0283
Book Now
New Patient Registration
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Patient Information
Prefix
Mr.
Mrs.
Ms.
Dr.
Name
(Required)
First Name
M. I.
Last Name
Nickname
Sex
(Required)
Male
Female
Birthdate
(Required)
Age
(Required)
Soc. Sec. #
Email
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Tel
Cell #
(Required)
Have you ever been a patient of our practice?
(Required)
Yes
No
Dentist
First
Last
Medical Doctor
First
Last
Referred By
First
Last
Driver's Lic. #
Nearest relative not living with you
First
Last
Tel.
Employer
Bus. Tel.
Who will be responsible for your account?
(Required)
Self
Spouse
Father
Mother
Other
Who will be responsible for your account?
Name
First
Last
Birthdate
Age
Tel
S. S.#
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Employer
Bus. Tel.
Spouse or other guarantor information (if different from above)
Name
First
Last
Relation
Birthdate
S. S.#
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Tel
Employer
Bus. Tel.
INSURANCE INFORMATION
Student
(Required)
Full Time
Part Time
Not
Status
(Required)
Married
Divorced
Legally Separated
Widow
Single
Employed
(Required)
Full Time
Part Time
Retired
Not
School Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Do you belong to PPO or HMO?
Yes
No
Primary Dental Insurance Company
Employer
Bus. Address
Bus. Tel
Plan
Insurance Company Name
Address
Tel
Group #
Group Name
Insured Policy Holder
Name
Relation
Relation
Sex
Male
Female
Birthdate
Address
Telephone
S.S. #
ID #
Primary Medical Insurance Company
Employer
Bus. Address
Bus. Tel
Plan
Insurance Company Name
Address
Tel
Group #
Group Name
Insured Party
Name
Relation
Relation
Sex
Male
Female
Birthdate
Address
Tel
S.S. #
ID #
Secondary Dental Insurance Company
Employer
Bus. Address
Bus. Tel
Plan
Insurance Company Name
Address
Tel
Group #
Group Name
Insured Party
Relation
Sex
Male
Female
Birth Date
Address
Tel.
S.S #
I.D. #
Secondary Medical Insurance Company
Employer
Bus. Address
Bus. Tel
Plan
Insurance Company Name
Address
Tel
Group #
Group Name
Insured Party
Relation
Sex
Male
Female
Birth Date
Address
Tel
S.S. #
I.D. #
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 beconsidered confidential.
Reason for today's office visit
Are you in good health?
(Required)
Yes
No
Height
(Required)
Weight
(Required)
Have there been any changes in your general health in the past year?
(Required)
Yes
No
Are you under the care of a physician?
(Required)
Yes
No
If so, for what are you being treated?
Date of last visit:
Have you had any serious illness, operation, or been hospitalized in the past five years?
(Required)
Yes
No
If so, describe
Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
(Required)
Yes
No
If so, describe where
Do you have a prosthetic joint/implant?
(Required)
Yes
No
If so, describe where
Have you had a heart valve replacement or vascular graft?
(Required)
Yes
No
Have you had or do you currently have...
Rheumatic Fever
(Required)
Yes
No
Damaged heart valves / mitral valve prolapse
(Required)
Yes
No
Heart murmur
(Required)
Yes
No
High Blood Pressure
(Required)
Yes
No
Low Blood Pressure
(Required)
Yes
No
Chest pain / angina
(Required)
Yes
No
Heart attack(s)
(Required)
Yes
No
Irregular Heart Beat
(Required)
Yes
No
Cardiac Pacemaker
(Required)
Yes
No
Heart Surgery
(Required)
Yes
No
Bronchitis, chronic cough
(Required)
Yes
No
Asthma
(Required)
Yes
No
Hay fever or sinus problems
(Required)
Yes
No
Snoring / sleep apnea
(Required)
Yes
No
Difficult breathing / other lung trouble
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Emphysema
(Required)
Yes
No
Do you smoke
(Required)
Yes
No
Do you use chewing tobacco
(Required)
Yes
No
Blood transfusion
(Required)
Yes
No
Blood disorder, such as anemia
(Required)
Yes
No
Bruise easily
(Required)
Yes
No
Bleeding tendency / abnormal bleed
(Required)
Yes
No
Hepatitis, jaundice or liver disease
(Required)
Yes
No
Infectious mononucleosis
(Required)
Yes
No
Gallbladder trouble
(Required)
Yes
No
Fainting spells
(Required)
Yes
No
Convulsion or epilepsy
(Required)
Yes
No
Stroke
(Required)
Yes
No
Thyroid trouble
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Low blood sugar
(Required)
Yes
No
Kidney trouble
(Required)
Yes
No
Are you in Dialysis
(Required)
Yes
No
Swollen ankles, arhtritis, or joint disease
(Required)
Yes
No
Stomach Ulcers
(Required)
Yes
No
Contagious Diseases
(Required)
Yes
No
Sexually transmitted diseases
(Required)
Yes
No
Are you immunosuppressed, possibly from transplant surgery, etc.
(Required)
Yes
No
Problems with the immune system? Instead of possibly from medication / surgery, etc.
(Required)
Yes
No
Delayed Healing
(Required)
Yes
No
Tumor or growth
(Required)
Yes
No
Radiation Therapy / chemotherapy
(Required)
Yes
No
Chronic fatigue / night sweats
(Required)
Yes
No
Are you on a diet
(Required)
Yes
No
History of drug abuse
(Required)
Yes
No
History of alcohol abuse
(Required)
Yes
No
Contact Lenses
(Required)
Yes
No
Eye disease / glaucoma
(Required)
Yes
No
Mental Health Problems
(Required)
Yes
No
Removable dental appliance
(Required)
Yes
No
Pain and clicking of jaws when eating
(Required)
Yes
No
Malignant hyperthermia
(Required)
Yes
No
IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?
(Required)
Yes
No
Who is driving you home?
Medication- Are you now taking or have you taken.
Any kind of medication, drug, pills?
(Required)
Yes
No
Blood thinners, (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)?
(Required)
Yes
No
Have you ever taken diet pills?
(Required)
Yes
No
Any natural or herbal product, supplement, or homeopathic remedy?
(Required)
Yes
No
Any bone density medications / Bisphosphonates (Aredia , Zometa , Fosamax, Actonel)?
(Required)
Yes
No
Have you ever taken tranquilizers, sleeping pills, anti-depressants and / or narcotics on a reqular basis ?
(Required)
Yes
No
Have you ever taken tranquilizers, sleeping pills, anti depressants, and / or narcotics on a reqular basis ? if so please list
Please list any medications you are currently taking:
(Required)
Allergies - Are you allergic to or have you had a reaction to…
Local anesthetic (numbing med)
(Required)
Yes
No
Penicillin
(Required)
Yes
No
Other Antibiotics
(Required)
Yes
No
Sulfa Drugs
(Required)
Yes
No
Sodium Pentothal, Valium, or other tranquilizers
(Required)
Yes
No
Aspirin
(Required)
Yes
No
Codeine or other narcotics
(Required)
Yes
No
Other Medications
(Required)
Yes
No
Latex
(Required)
Yes
No
Soy
(Required)
Yes
No
Eggs / Yolk
(Required)
Yes
No
Sulfites
(Required)
Yes
No
Please list any allergies other than drug allergies:
Is there any condition concerning your health that the Doctor should be told about?
Yes
No
Do you wish to speak to the doctor privately about anything?
Yes
No
Is there any condition concerning your health that the Doctor should be told about? (if so, describe)
Is there a FAMILY HISTORY of:
Cancer:
Yes
No
Diabetes:
Yes
No
Heart Disease:
Yes
No
Anesthetic Problems:
Yes
No
IN CASE OF EMERGENCY, CONTACT:
Name
Home Tel.
Bus. Tel.
IS THIS VISIT RELATED TO AN ACCIDENT?
Automobile
Yes
No
Work Related:
Yes
No
Other:
Yes
No
Date of Injury
Isurance company handling this claim
Claim number
Name of Attorney / Adjustor
Telephone Number
THIS SECTION IS FOR WOMEN ONLY, MEN CONTINUE BELOW. WOMEN, CONTINUE BELOW WHEN YOU HAVE COMPLETED THIS SECTION.
Is there a possibility of pregnancy?
Yes
No
Expected delivery date
Are you nursing?
Yes
No
Are you taking birth control pills?
Yes
No
Women Note:
Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.
Pharmacy Information
Name
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Consent
(Required)
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 surgeon, or any other members of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
Signature
(Required)
Hidden
Reviewed by:
Date
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