Patient Biography and Insurance Information

Patient Information
First Name: Last Name: Age: Birthdate:
Address:  City:  State: Zip:
Home Phone: Cell Phone: Work Phone:
Social Security Number:
Parent, Spouse or Emergency Contact
First Name: Last Name: Home Phone:
Relationship: Cell Phone: Work Phone:
To whom may we thank for your referral?
Has anyone else in your family been a patient of Dr.Harris?
Dental Insurance
Insured First Name: Insured Last Name: Birthdate:
Address if different from above: City: State: Zip:
Home Phone: Cell Phone:
Social Security Number or ID#:
Insurance Company: Phone Number:
Policy/Group Number:
Name of Employer: Phone Number:
Financial Authorization
        I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize High Desert Oral Surgery and Implant Center, PLC to release all information necessary to secure payment of benefits and I authorize the use of the signature below on all insurance submissions.
       I assign any insurance benefits directly to High Desert Oral Surgery and Implant Center, PLC.
Signature of Patient (Parent): Date:

Medical History Questionnaire
First Name: Last Name: DOB: Age:  
       Height:    Weight:
Medical History:
    1) Are you in good health?  
    2) Do you have any medical problems?    If Yes, Please Describe Below
    3) Have you ever been hospitalized? (Including Childbirth & Surgery)   If Yes, Please Describe Below
    4) Has there been any change to health recently?  
    5) Do you have or have you had?    
          a) Heart murmur or damaged/artificial heart valves?  
          b) Rheumatic heart disease? Any Infectious Disease? HIV?  
          c) Any artificial joints? 
  Have you ever been advised to take antibiotics before dentistry?
          d) Any TMJ problems?  
          e) Coronary Heart Disease? Heart attack or Angina? 
          f) High Blood Pressure? 
          g) Kidney Disease? Renal  Failure? Dialysis? 
          h) Stroke or CVA/TIA? 
          i) Diabetes?  Last Finger Stick was
          j) Seizures, Epilepsy or other Neurologic Disease? 
          k) Do you Smoke? How Often? 
          l) Respiratory Disorders (Asthma, Emphysema, Bronchitis)? 
         m) Hepatitis or Liver Disease? 
         n) Mental Depression or Psychiatric Care? 
         o) Osteoporosis? Osteopenia? 
         p) Do you bruise easily or have abnormal bleeding?  
         q) Have you ever had treatment for a tumor/growth?  
         r) Any other medical issue not mentioned above?  

     1) Please list all medications, herbs, vitamins:  
     2) Do you take aspirin, plavix or coumadin regularly?   Last INR was
     3) Do you take Fosamax, Actonel, Boniva (Bisphosphonates) ? 
     4) Do you use any illegal or recreational drugs? (Confidential) 
    1) Are you allergic to any drugs? 
Describe the reaction you have had from:    
        a) Penicillin, Clindamycin or other antibiotics?  
        b) Codeine or other narcotics? 
        c) Local anesthetics (Lidocaine, Marcaine...)? 
        d) Aspirin? Ibuprofen? Advil? Motrin? NSAIDS?
        e) Latex? 
         f) Anything else?
Is there anything you would like to share with Dr. Harris in Private?
Women Only:
        1) Is it possible you are pregnant? Are you nursing?
        2) Are you currently taking birth control pills?
Office Policy:  I have read and accept the Office Policy Packet and HIPAA Privacy Notice.
(You will be given a copy of all policies at your consultation appointment)
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the above questions have been answered to my satisfaction. I will not hold Dr. Harris or his staff responsible for any errors or omissions that I have made in the completion of this form. Furthermore, I authorize Dr. Harris to communicate with my other healthcare providers to facilitate the coordination of my care.  
Patient Signature: Date: