New Patient Form | The Oral Maxillofacial & Implant Surgery Center

Patient Information

Your Name?

Prefix Mr. Mrs. Ms. Dr.

First M.I. Last

Do you have a nickname?

Yes No

Nickname:

Gender?

Male Female

Birth Date?

Age?

Marital Status?

Email Address?

Address?

Street

City

State

Zip

Phone Numbers?

Daytime

( ) -

Cell

( ) -

Have you ever been a patient of our practice?

Yes No

Do you have a dentist?

Yes No

Dentist's First Name

Dentist's Last Name

Do you have a medical doctor?

Yes No

Medical Doctor's First Name

Medical Doctor's Last Name

Were you referred to us?

Yes No

Referrer's First Name

Referrer's Last Name

Do you have a driver's license?

Yes No

Driver's License #

Nearest relative not living with you?

First Name

Last Name

Phone Number

( ) -

Are you currently employed?

Yes No

Employer's Name

Business Phone

( ) -

Personal Payment Type?

Cash Check Credit Card

Who will be responsible for your account?

Self Spouse Father Mother Other

Other Account Guarantor

Account Guarantor

Your Name?

Prefix Mr. Mrs. Ms. Dr.

First M.I. Last

Birth Date?

Age?

Phone Numbers?

Home

( ) -

Cell

( ) -

Address?

Street

City

State

Zip

Employer Information

Employer's Name

Business Phone

( ) -

Insurance Information

Student Status?

Full Time Part Time Not

School Name

School Street Address

School City

School State

School Zip

What is your marital status?

Married Divorced Legally Separated

Widow Single

What is your employment status?

Full Time Part Time Retired Not

Do you belong to a PPO or HMO?

Yes No

Do you have insurance?

Dental insurance?

Yes No

Secondary dental insurance?

Yes No

Medical insurance?

Yes No

Secondary medical insurance?

Yes No

Dental Insurance

Employer

Name

Address?

Street

City

State

Zip

Business Phone

( ) -

Insurance Plan

Insurance Company

Name

Address?

Street

City

State

Zip

Phone

( ) -

Group

Group #

Group Name

Insured Party

Name

First Last

Relation

Gender

Male Female

Birth Date

Address?

Street

City

State

Zip

Phone

( ) -

I.D. #

Secondary Dental Insurance

Employer

Name

Address?

Street

City

State

Zip

Business Phone

( ) -

Insurance Plan

Insurance Company

Name

Address?

Street

City

State

Zip

Phone

( ) -

Group

Group #

Group Name

Insured Party

Name

First Last

Relation

Gender

Male Female

Birth Date

Address?

Street

City

State

Zip

Phone

( ) -

I.D. #

Medical Insurance

Employer

Name

Address?

Street

City

State

Zip

Business Phone

( ) -

Insurance Plan

Insurance Company

Name

Address?

Street

City

State

Zip

Phone

( ) -

Group

Group #

Group Name

Insured Party

Name

First Last

Relation

Gender

Male Female

Birth Date

Address?

Street

City

State

Zip

Phone

( ) -

I.D. #

Secondary Medical Insurance

Employer

Name

Address?

Street

City

State

Zip

Business Phone

( ) -

Insurance Plan

Insurance Company

Name

Address?

Street

City

State

Zip

Phone

( ) -

Group

Group #

Group Name

Insured Party

Name

First Last

Relation

Gender

Male Female

Birth Date

Address?

Street

City

State

Zip

Phone

( ) -

I.D. #

Health History

Reason for today's office visit?

Your Height?

Your Weight?

Are you in Good Health?

Yes No

Please Describe:

Have there been any changes in your general health in the past year?

Yes No

Please Describe:

Are you under the care of a physician?

Yes No

Physician's Name?

Date of last visit?

For what?

Have you had an operation or been hospitalized in the last 5 years?

Yes No

Please Describe:

Do you have a prosthetic joint?

Yes No

Please Describe:

Do you have or have you had any of the following?

Heart Problems?

Yes No

Damaged Heart Valve?

Yes No

Please Describe:

Valve Replacement?

Yes No

Please Describe:

High / Low Blood Pressure?

Yes No

Please Describe:

Chest Pain?

Yes No

Please Describe:

Angina?

Yes No

Please Describe:

Heart Attack?

Yes No

Please Describe:

Irregular Heart Beat?

Yes No

Please Describe:

Pacemaker?

Yes No

Please Describe:

Swollen Ankles?

Yes No

Please Describe:

Heart Surgery?

Yes No

Please Describe:

Breathing Problems?

Yes No

Asthma?

Yes No

Please Describe:

Bronchitis / Chronic Cough?

Yes No

Please Describe:

Snoring / Sleep Apnea?

Yes No

Please Describe:

Tuberculosis?

Yes No

Please Describe:

Emphysema?

Yes No

Please Describe:

Female Questionaire

Is there ANY POSSIBILITY you are pregnant?

Yes No

Expected delivery date?

Any problems?

Physician?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Antibiotics (such as penicillin, amoxicillin, and others) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

I have read, understand, and agree to this statement

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 member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Please answer all questions