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

Cell Phone#:
Home Phone#:
Last Name First Age Sex Weight Height
Home Address City State Zip
Birth Date
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?
Has Dr. Minkin and/or Associates ever treated patient or any member of patient's family?
         Who was the prior patient?
Person Responsible for this Account (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

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? 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 #

1. How is your general medical health?
2. Have you been under the care of a physician during the past year?
If yes, whom?
3. Are you taking any drugs or medicines now (please include herbs/natural medication)?
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?
If yes, what?
4a. Do you have any food allergies?
If yes, what?
4b. Are you allergic to latex?
5. Have you ever had a serious illness?
If yes, what?
6. Do you have any unusual shortness of breath or limitation of activity?
If yes, what?
7. Have you ever used street drugs or recreational drugs?
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?
11. Do you drink alcohol daily?
12. Do you use marijuana routinely?
13. Do you wear contact lenses?
14. Have you ever had pain, clicking, or popping of your jaw joint (TMJ problems)?
15. Have you ever had excessive bleeding following an extraction, cut, or surgery?
16. Have you or any relatives had an unfavorable reaction to local or general anesthesia?
17. Have you had any operations or hospitalizations?
18. (Women) Are you pregnant or breast-feeding?
19. Please list any items not mentioned above which you wish to bring to our attention?
If yes, please list: 
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:
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     
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