Patient Information
Insurance Information
Fees and 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, attorney fees, and court costs.

Medical History

What is your reason/s for visiting our practice?

Are you in good health?YesNo
Have there been any changes in your general health in the past year?YesNo

Date of last physical exam:

Are you now under the care of a physician?YesNo
Have you had trouble with previous medical, dental or surgical treatments?YesNo
Have you experienced abnormal bleeding with previous surgeries, extractions or trauma?YesNo
Have you had any serious illness, operation or hospitalization in the past 5 years?YesNo
Do you bruise easily?YesNo
Have you ever required a blood transfusion? YesNo
Have you had surgery or radiation for a tumor, cancer or other head/neck condition?YesNo
Have you taken the diet pills Fen-Phen, Pondimin or Redux?YesNo
If yes, have you had a medical exam to ensure your heart valves were not affected?YesNo
Do you wear contact lenses? YesNo
Are you allergic to or have you reacted to any of the following:
Local Anesthesia (Procaine, Novocaine, etc.)
Codeine or other narcotics
Penicillin, Amoxicillin, Cephalosporins, Sulfa
Nitrous oxide (Laughing Gas)
Aspirin or Ibuprofen
Other Allergy:
Latex Gloves
Do you have or have you had any of the following diseases or problems:
Rheumatic Fever or Rheumatic Heart Disease
Fainting Spells or Seizures
Cardiovascular Disease (Heart Trouble)
Heart Attack, Angina, Chest Pain, Stroke
Hepatitis, Jaundice, or Liver Disease
High Blood Pressure
Arthritis or Other Joint Problems
Heart Murmur
Stomach Ulcers
Shortness of Breath
Kidney Trouble
Asthma of Emphysema
Venereal Disease (Past or Present)
Tuberculosis or any Lung Disease Persistent
Blood Disorder (Hemophilia, Anemia, or Other)
Cough or Coughing up Blood
Other Conditions the Doctor Should Know:
Autoimmune Disorders (HIV or AIDS)
Are you taking any of the following medications:
HIV medications
Insulin, Tolbutamide, Glyburide, or similar drugs
Antibiotics or Sulfa drugs
Digitalis, Nitroglycerin, or drugs for heart trouble
Anticoagulants (blood thinners)
Cortisone or steroids, including Prednisone
Oral contraceptive or hormonal therapy
Other medication:
Women Only
Are you pregnant or have you missed a menstrual cycle?YesNo
Are you currently breastfeeding?YesNo

Antibiotics may make birth control pills less effective. Consult your doctor and consider alternate methods of birth control.

I have read and understand this statement about birth control pills – PLEASE INITIAL:

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

Who is driving you home?


I certify that I have read and 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.

Patient Signature:



I authorize my surgeon and his/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. I 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.

Patient Signature:


Fees and Payments:

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Patient Signature:


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