Registration Form

Please Fill in the Required Information

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Patient Full Name *(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Cell Phone Number

Referring Doctor

Emergency Contact(Required)

Phone(Required)

Full Time Student

Yes

If yes, name of college

Responsible Party Info/Insurance Subscriber Info: *The family member your insurance is through

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Relationship to Patient(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Cell Phone Number

Employer

Medical Insurance Carrier

Member ID No.

Group ID No.

Phone No.

Dental Insurance Carrier

Member ID No.

Group ID No.

Phone No.

Signature *(Required)

Date(Required)

MM slash DD slash YYYY

OFFICE NOTES - Leave Blank- For Office Use Only

Medical History

Name(Required)

Height(Required)

Weight(Required)

Age(Required)

ALLERGIES & MEDICATION

Please list all known allergies(Required)

Please list all current medications(Required)

*Please answer all questions correctly and completely. Your answers are for our records only and will be kept confidential.

Are you in good health?(Required)

Yes

Date of Last Physical Exam

MM slash DD slash YYYY

Has there been any change in your health in the past year?(Required)

Yes

Are you now under the care of a physician?(Required)

Yes

If yes, for what condition?(Required)

Physician’s Full Name(Required)

Have you had any serious illness, operation, or hospitalization?(Required)

Yes

If yes, please explain(Required)

Are you taking or have you ever taken bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, or other antiresorptive drugs?(Required)

Yes

Are you pregnant?(Required)

Yes

Are you nursing?(Required)

Yes

Are you taking birth control?(Required)

Yes

Do you wear contact lenses?(Required)

Yes

Do you have any of the following diseases or problems?(Required)

Rheumatic Heart Disease

Low/High Blood Pressure

Shortness of Breath/Emphysema

Heart Attack

Heart Surgery/Valve Replacement

Chest Pain

Heart Murmur

Any Other Heart Trouble

Anemia or Other Blood Disorder

Abnormal Bleeding

Other Blood Disorder

Stroke

Frequent Mouth Sores

Neurologic Disorder or Epilepsy

Anxiety or Psychiatric Conditions

Fainting Spells or Seizures

Kidney Trouble

Osteoporosis

Prosthetic Joint(s)

Diabetes

Thyroid Problems

Hepatitis, Jaundice, or Liver Disease

Stomach Ulcers/Reflux

Immune Deficiency

AIDS/HIV Positive

Arthritis or Painful Joints (Including TMJ)

Asthma or Hay Fever

Respiratory Problems

Sinus Trouble

Persistent Cough

Tuberculosis

Tumor or Cancerous Growth

Radiation Treatment or Chemotherapy

Persistent Swollen Neck Glands

Alcohol or Chemical Dependency

Smoke or Chew Tobacco

Other condition doctor should know

Do you wish to talk with the doctor privately about anything?(Required)

Yes

Signature *(Required)

Date(Required)

MM slash DD slash YYYY

Privacy Practices

My signature below indicates that I have been given the chance to review a current copy of my doctor’s “Notice of Privacy Practices.” My signature means that I agree to allow my doctor to use and disclose my personal information to carry out treatment, payment, and other necessary healthcare operations.

Signature *

Date

MM slash DD slash YYYY

Fees and Payment

I understand and agree that all fees are the responsibility of the patient and/or responsible party, due and payable within 90 days from the day of service, irrespective and regardless of any insurance claims or other anticipated benefits. Account balances older than 90 days will be subject to interest charges in the amount of 18% per annum, and further subject to collection fees which would accrue should it become necessary to enlist an outside agency for collection services.

Patient Signature *(Required)

Date(Required)

MM slash DD slash YYYY

I hereby authorize payment directly to Oral Facial Surgery Institute, Inc., of benefits due me for services provided by him and/or his representatives. I understand that I am financially responsible for the entire cost of services provided regardless of insurance coverage. I hereby authorize the release of any information acquired in the course of my treatment as may be necessary to process my insurance claim.

Patient Signature *(Required)

Date(Required)

MM slash DD slash YYYY

Authorization for Release of Information to Family and/or Friends

Patient Name

Date of Birth

MM slash DD slash YYYY

Oral Facial Surgery Institute, Inc. is authorized to release protected health information about the above-named patient to the entities named below.

Medical Information

Results from Tests or X-rays

Financial Information

Family/Friend Name

Phone

Family/Friend Name

Phone

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Registration Form

Please Fill in the Required Information