ORALCARE   ASSOCIATES Oral & Maxillofacial Surgery Dale H. Minkin, D.D.S. Diplomate, American Board of Oral and Maxillofacial Surgery 39350 Civic Center Drive Suite 320 Fremont, CA 94538 Tel (510) 797-9100 Fax (510) 797-3429

WELCOME TO OUR PRACTICE

Date: Cell Phone#: Home Phone#:

Last Name First Age Sex MF Weight Height

Home Address City State Zip

Birth Date SingleMarriedDivorcedSeparatedWidowed

Social Security Number of Patient

If patient is fulltime student: School Name City State

Patient's Dentist Phone Date of Last Visit Patient's Physician Phone Date of Last Physical/Visit

Email Address

May we correspond with you via email or text? YesNo

Has Dr. Minkin and/or Associates ever treated patient or any member of patient's family? YesNo          Who was the prior patient?

Person Responsible for this Account SelfParent/Legal Guardian (Name )

If patient is a minor, whom does the patient reside with?

Driver's License of person responsible for account

Employer Phone Ext.

Spouse's/Parent's Name

Employer Phone Ext.

Whom may we thank for referring you to our office?

Nearest Relative

FOR PATIENTS WITH INSURANCE

Dental Insurance (Primary)   Insured Person's Name SS# of Insured   Name of Insurance Group #   Insurance Address Insurance Phone # Is there secondary dental insurance for the patient? YesNo If yes, please give us the following:   Insured Person's Name SS# of Insured   Name of Insurance Group #   Insurance Address Insurance Phone # Primary Insured Birthday Secondary Insured Birthday

Medical & Hospitalization Insurance

Name of Company of Carrier

Address of Medical Insurance

Plan or Group #

If patient has Kaiser coverage, please list #

PLEASE ANSWER ALL QUESTIONS

1. How is your general medical health? ExcellentGoodFairPoor 2. Have you been under the care of a physician during the past year? YesNo If yes, whom? 3. Are you taking any drugs or medicines now (please include herbs/natural medication)? YesNo If yes, what? 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.   4. Are you allergic to any drugs or medicines? YesNo If yes, what? 4a. Do you have any food allergies? YesNo If yes, what? 4b. Are you allergic to latex? YesNo 5. Have you ever had a serious illness? YesNo If yes, what? 6. Do you have any unusual shortness of breath or limitation of activity? YesNo If yes, what? 7. Have you ever used street drugs or recreational drugs? YesNo If yes, what? 8. Do you now have or have you ever had any of the following? Yes  No Yes  No Yes  No Heart Problem Diabetes Tuberculosis Emphysema Syphilis Epilepsy Rheumatic Fever Chronic Cough Kidney Disease Hepatitis or Jaundice Anemia Heart Murmur Angina (Chest Pain) Asthma Thyroid Disease High Blood Pressure Stomach Problems Cancer Glaucoma Arthritis Blood Clotting Disorder (Bleeder) Blood Disease Sinus Problem Blood Transfusion H.I.V. + Test/AIDS Drug Abuse Eye Surgery 9. Are you now taking or have you ever taken any of the following medications? Yes  No Yes  No Cortisone or Steroids Anticoagulants (Blood thinners) Asthma Medicines Aspirin for a long period of time Heart or Blood Pressure Medications Birth Control Pills Tranquilizers or Sedatives Diet Pills (Prescription or over the counter) Other Drugs/Herbal-Natural Medications Insulin or Oral Medication for Diabetes If yes, please list:  Fosamax or any drugs for bone density If yes, please list:  10. Do you use any tobacco products at all? YesNo 11. Do you drink alcohol daily? YesNo 12. Do you use marijuana routinely? YesNo 13. Do you wear contact lenses? YesNo 14. Have you ever had pain, clicking, or popping of your jaw joint (TMJ problems)? YesNo 15. Have you ever had excessive bleeding following an extraction, cut, or surgery? YesNo 16. Have you or any relatives had an unfavorable reaction to local or general anesthesia? YesNo 17. Have you had any operations or hospitalizations? YesNo 18. (Women) Are you pregnant or breast-feeding? YesNo 19. Please list any items not mentioned above which you wish to bring to our attention? None If yes, please list:

PLEASE INQUIRE ABOUT ANY QUESTIONS WHICH ARE NOT UNDERSTOOD

By my signature below, I agree and indicate that the above information is correct and current to the best of my knowledge, that I give consent to secure records such as X-rays, models, photographs, etc and perform whatever diagnostic procedures deemed necessary, and that all consent forms signed are an integral part of this treatment record and that neither is complete without the other. If I am unable to keep an appointment, I will give 48 hour notice, otherwise a charge will be made for the time reserved.

Date ________________________ Patient _________________________________________   Patient or Legal Guardian ___________________________

If you would like us to share medical or financial information with anyone other than you, please complete the following:

AUTHORIZATION FOR RELEASE OF MEDICAL/DENTAL RECORDS

I hereby request and authorize the release of all information, without limitations, regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future. This includes photocopies of medical and/or dental histories, x-ray findings, diagnosis, treatment, prognosis and financial records. I request that you release the above information to:

Fill in the recipient

Address

City   State   Zip

Patient's(or Legal Guardian's) Signature   Date

Witness's Signature    Date

Acknowledgement of Receipt of Notice of Privacy Policies. I have received a copy of OralCare Associates Notice of Privacy Policies.   Signature Date

Patient Consent Form     Summary of Privacy Practices Form

Date ________________________ Signed ________________________ Changes Yes No