Meet the Doc
Services
Bone Grafting
Facial Trauma
Implants
Jaw Surgery
Oral Pathology
Pre-Prosthetic
Sedation Dentistry
Wisdom Teeth Removal
For Patients
New Patient Registration
Financing by Proceed Finance
Insurance
Contact
Mon - Fri: 8am - 5pm
801-285-9693
+1 812-282-8467
Book Now
Meet the Doc
Services
Bone Grafting
Facial Trauma
Implants
Jaw Surgery
Oral Pathology
Pre-Prosthetic
Sedation Dentistry
Wisdom Teeth Removal
For Patients
New Patient Registration
Financing by Proceed Finance
Insurance
Contact
New Patient Registration Form
Asset 18
New Patient Registration
Asset 22
Make An Appointment
Asset 23
Referring Doctor
Step
1
of
5
20%
Patient Information
Prefix
Mr.
Mrs.
Ms.
Dr.
Name
(Required)
First Name
M. I.
Last Name
Nickname
Sex
(Required)
Male
Female
Birthdate
(Required)
Age
(Required)
Email
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Tel
Cell #
(Required)
Have you ever been a patient of our practice?
(Required)
Yes
No
Dentist
First
Last
Medical Doctor
First
Last
Referred By
First
Last
Driver's Lic. #
Nearest relative not living with you
First
Last
Tel.
Employer
Bus. Tel.
Who will be responsible for your account?
(Required)
Self
Father
Other
Spouse
Mother
Who will be responsible for your account?
Name
First
Last
Birthdate
Age
Tel
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Employer
Bus. Tel.
Spouse or other guarantor information (if different from above)
Name
First
Last
Relation
Birthdate
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Tel
Employer
Bus. Tel.
INSURANCE INFORMATION
Student
(Required)
Full Time
Part Time
Not
Status
(Required)
Married
Divorced
Legally Separated
Widow
Single
Employed
(Required)
Full Time
Part Time
Retired
Not
School Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Do you belong to PPO or HMO?
Yes
No
Primary Dental Insurance Company
Employer
Insurance Company Name
Address
Group #
Tel
Policy #
Insured Policy Holder
Name
Relation
Birthdate
ID #
Primary Medical Insurance Company
Employer
Insurance Company Name
Address
Group #
Tel
Policy #
Insured Policy Holder
Name
Relation
Birthdate
ID #
Medication- Are you now taking or have you taken.
Any kind of medication, drug, pills?
(Required)
Yes
No
Blood thinners, (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)?
(Required)
Yes
No
Have you ever taken diet pills?
(Required)
Yes
No
Any natural or herbal product, supplement, or homeopathic remedy?
(Required)
Yes
No
Any bone density medications / Bisphosphonates (Aredia , Zometa , Fosamax, Actonel)?
(Required)
Yes
No
Have you ever taken tranquilizers, sleeping pills, anti-depressants and / or narcotics on a reqular basis ?
(Required)
Yes
No
Have you ever taken tranquilizers, sleeping pills, anti depressants, and / or narcotics on a reqular basis ? if so please list
Please list any medications you are currently taking:
(Required)
Allergies - Are you allergic to or have you had a reaction to…
Local anesthetic (numbing med)
(Required)
Yes
No
Penicillin
(Required)
Yes
No
Other Antibiotics
(Required)
Yes
No
Sulfa Drugs
(Required)
Yes
No
Aspirin
(Required)
Yes
No
Sodium Pentothal, Valium, or other tranquilizers
(Required)
Yes
No
Codeine or other narcotics
(Required)
Yes
No
Other Medications
(Required)
Yes
No
Latex
(Required)
Yes
No
Soy
(Required)
Yes
No
Eggs / Yolk
(Required)
Yes
No
Sulfites
(Required)
Yes
No
Please list any allergies other than drug allergies:
To our patients:
Although oral surgeons primarily treat the area in and around your mouth, various health problems and medications can have an important interrelationship with the care you will receive. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Are you in good health?
(Required)
Yes
No
Height
(Required)
Weight
(Required)
Have there been any changes in your general health in the recent years?
(Required)
Yes
No
Have there been any changes in your general health in the past years?
Are you under the care of a physician?
(Required)
Yes
No
If so, for what are you being treated?
Date of last visit:
Have you had any serious illness, operation, or been hospitalized in the past five years?
(Required)
Yes
No
If so, describe
Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
(Required)
Yes
No
If so, describe where
Do you have a prosthetic joint/implant?
(Required)
Yes
No
If so, describe where
Have you had a heart valve replacement or vascular graft?
(Required)
Yes
No
Have you had or do you currently have...
Rheumatic Fever
(Required)
Yes
No
Damaged heart valves / mitral valve prolapse
(Required)
Yes
No
Heart murmur
(Required)
Yes
No
High Blood Pressure
(Required)
Yes
No
Chest pain / angina
(Required)
Yes
No
Heart attack(s)
(Required)
Yes
No
Irregular Heart Beat
(Required)
Yes
No
Cardiac Pacemaker
(Required)
Yes
No
Heart Surgery
(Required)
Yes
No
COPD, Bronchitis, chronic cough
(Required)
Yes
No
Asthma
(Required)
Yes
No
Hay fever or sinus problems
(Required)
Yes
No
Snoring / sleep apnea
(Required)
Yes
No
Difficult breathing / other lung trouble
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Emphysema
(Required)
Yes
No
Do you smoke
(Required)
Yes
No
Do you use chewing tobacco
(Required)
Yes
No
Blood transfusion
(Required)
Yes
No
Blood disorder, such as anemia
(Required)
Yes
No
Bruise easily
(Required)
Yes
No
Bleeding tendency / abnormal bleed
(Required)
Yes
No
Hepatitis, jaundice or liver disease
(Required)
Yes
No
Infectious mononucleosis
(Required)
Yes
No
Gallbladder trouble
(Required)
Yes
No
Fainting spells
(Required)
Yes
No
Convulsion or epilepsy
(Required)
Yes
No
Stroke
(Required)
Yes
No
Thyroid double
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Low blood sugar
(Required)
Yes
No
Kidney trouble
(Required)
Yes
No
Are you in Dialysis
(Required)
Yes
No
Swollen ankles, arthritis, or joint disease
(Required)
Yes
No
Stomach Ulcers
(Required)
Yes
No
Contagious Diseases
(Required)
Yes
No
Sexually transmitted diseases
(Required)
Yes
No
Are you immunosuppressed, possibly from transplant surgery, etc.
(Required)
Yes
No
Problems with the immune system? Instead of possibly from medication / surgery, etc.
(Required)
Yes
No
Delayed Healing
(Required)
Yes
No
Tumor or growth
(Required)
Yes
No
Radiation Therapy / chemotherapy
(Required)
Yes
No
Chronic fatigue / night sweats
(Required)
Yes
No
Are you on a diet
(Required)
Yes
No
History of drug abuse
(Required)
Yes
No
History of alcohol abuse
(Required)
Yes
No
Contact Lenses
(Required)
Yes
No
Eye disease / glaucoma
(Required)
Yes
No
Mental Health Problems
(Required)
Yes
No
Removable dental appliance
(Required)
Yes
No
Pain and clicking of jaws when eating
(Required)
Yes
No
Malignant hyperthermia
(Required)
Yes
No
IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?
(Required)
Yes
No
Who is driving you home?
Consent
(Required)
I certify that I have read and I understand the questions above. I acknowledge that my questions , if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other members of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
Signature
(Required)
Δ
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+1 812-282-8467
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