This form is HIPAA compliant to ensure privacy.

Montgomery Oral and Facial Surgery

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New Patient Registration Form

Patient Information

Title:

Sex:
First Name:

Date of Birth:

Nickname:
Age:
(calculated after submit)
Middle Initial:
Social Security #:
Last Name:
 

 Email:

 
Street Address:
Home Tel. #:
City:
Work Tel. #:
State:
Ext.:
Zip:
Mobile Tel#:
Employer Name:
Occupation:
 
Dentist:
Dentist Phone #:
Referred By:
Physician:
For Doctor:
Physician Phone #:
Spouse Name:
 
Emergency Contact:
Home Tel. #:
 Relation:
Work Tel. #:
 
Marital Status:

Have you ever been a patient of our practice?

How were you referred to our office?



Referral Name :

Method of Personal Payment:

Are you a student? 
 School:
Preferred appointment time:
 

Account Responsibility/Insurance Card Holder

Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

Social Security #:

Middle Initial:
Driver's License #:
Last Name: Home Tel. #
 

Street Address:

 Mobile Tel. #:

City:

Employer Name:

State:

Emp. Tel. #:

Zip:

(if other) Relation:


Spouse or Guarantor Info (if different from above)

Title:

Social Security #:

First Name:

Tel. #:

Middle Initial:

Mobile Tel#:

Last Name:

Employer Name:

 

Street Address:

Emp. Tel. #:

City:

Relation:

State:

 

Zip:


Primary Dental Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
Relationship to Patient:

Primary Medical Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

Secondary Insurance

Type of Insurance:

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

General Health

Are you in relatively good health?
Height:
Weight:
Have there been any changes in your general health in the past year?
If yes, please explain:
Are you under the care of a physician?
Date of last visit:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
If yes, please explain:
Do you have injuries or inflamed areas, growths or sore spots in or around your mouth?
Where:
Do you have a heart valve replacement or vascular graft?
Where:
Is this visit related to an accident?
When was the accident?
Are there conditions that the doctor should be aware of?
Please List:
Do you wish to speak to the doctor privately regarding your conditions?

Conditions

High / Low blood pressureChest pain / angina
Heart Murmur / Mitral Valve ProlapseIrregular heartbeat
Cardiac pacemakerHeart surgery
StrokeHeart attack(s)
Blood transfusionSwollen ankles, arthritis, or joint disease
Chronic fatigue / night sweatsRheumatic fever
Damaged heart valvesProblems with the immune system
Sexually transmitted diseasesTumor or growth
X-Ray treatment / chemotherapyInfectious mononucleosis
Delay in healingMalignant hyperthermia
Immunodeficiency disease I smoke
Difficult breathing / other lung troubleBronchitis / chronic cough
Asthma / EmphysemaHay fever / sinus problems
TuberculosisI am on a diet
Thyroid troubleLow blood sugar
DiabetesStomach ulcers
Gallbladder troubleBlood disorder such as anemia
Bruise easilyBleeding tendency (abnormal bleeding)
Mental health problemsHistory of drug / alcohol abuse
Convulsions / epilepsyFainting spells
Kidney trouble / DialysisEye Disease / Glaucoma
Contact lensesHepatitis
Pain & clicking of jaws when eatingProsthetic Joint
Other Medical Issues not listed above

Medication & Allergies

Are you taking any kind of medicine, drugs, or pills?
Please list: (especially for Bone Density i.e. Bisphosphonates)
Have you ever taken diet pills?
Please list:

Are you allergic to or have you ever had an adverse reaction to local anesthetics?
Are you allergic to or have you ever had an adverse reaction to aspirin?
Are you allergic to or have you ever had an adverse reaction to latex?
Are you allergic to or have you ever had an adverse reaction to penicillin?
Are you allergic to or have you ever had an adverse reaction to other medications?
Please list all allergies and adverse reactions that you are aware of below:

Women Only

Is it possible that you are currently pregnant?
Are you nursing?
Are you currently taking birth control medicine?

Family History (please  check  all  that  apply)







Fees and Payments
We make every effort to keep down the cost of your oral surgical 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, attorneys fees, and court costs.


I certify that I have read and understand the above. 
I authorize the release of information necessary to process my claim. I hereby authorize to this doctor named of the benefits otherwise payable to me. 
Patient Acknowledgements
I hereby acknowledge that I have been given the right to review the Notice of Privacy Practices for this office. (HIPAA) A copy of this notice can be viewed here.

I certify that I have read and understand the above.  I affirm that the information contained in this form and any additional information that I may furnish is true and correct to the best of my knowledge.  I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I will not hold Montgomery Oral and Facial Surgery  or the staff responsible for any errors or omissions that I have made in the completion of this form.

  
  Signature                                                                                                                 Date        

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