Please Fill in the Required Information Please enable JavaScript in your browser to complete this form.123Patient Full Name *Date of BirthSexSocial Security No.AddressApt No.CityStateZipPhone NumberCell Phone NumberEmail *Referring DoctorEmergency ContactPhoneFull Time StudentYesNoIf yes, name of collegeResponsible Party Info/Insurance Subscriber Info: *The family member your insurance is throughFull NameDate of BirthRelationship to PatientSocial Security No.AddressApt No.CityStateZipPhone NumberCell Phone NumberEmployerMedical Insurance CarrierMember ID No.Group ID No.Phone No.Dental Insurance CarrierMember ID No.Group ID No.Phone No.Signature *Clear SignatureDateOFFICE NOTES - Leave Blank- For Office Use OnlyNextMedical HistoryNameHeightWeightAgeALLERGIES & MEDICATIONPlease list all known allergiesPlease list all current medications*Please answer all questions correctly and completely. Your answers are for our records only and will be kept confidential.Are you in good health?YesNoHas there been any change in your health in the past year?YesNoDate of Last Physical ExamAre you now under the care of a physician?YesNoIf yes, for what condition?Physician’s Full NameHave you had any serious illness, operation, or hospitalization?YesNoIf yes, please explainAre 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?YesNoAre you pregnant?YesNoAre you nursing?YesNoAre you taking birth control?YesNoDo you wear contact lenses?YesNoDo you have any of the following diseases or problems?Rheumatic Heart DiseaseDiabetesLow/High Blood PressureThyroid ProblemsShortness of Breath/EmphysemaHepatitis, Jaundice, or Liver DiseaseHeart AttackStomach Ulcers/RefluxHeart Surgery/Valve ReplacementImmune DeficiencyChest PainAIDS/HIV PositiveHeart MurmurArthritis or Painful Joints (Including TMJ)Any Other Heart TroubleAsthma or Hay FeverAnemia or Other Blood DisorderRespiratory ProblemsAbnormal BleedingSinus TroubleOther Blood DisorderPersistent CoughStrokeTuberculosisFrequent Mouth SoresTumor or Cancerous GrowthNeurologic Disorder or EpilepsyRadiation Treatment or ChemotherapyAnxiety or Psychiatric ConditionsPersistent Swollen Neck GlandsFainting Spells or SeizuresAlcohol or Chemical DependencyKidney TroubleSmoke or Chew TobaccoOsteoporosisOther condition doctor should knowProsthetic Joint(s)Do you wish to talk with the doctor privately about anything?YesNoSignature *Clear SignatureDatePreviousNextPrivacy PracticesMy 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 *Clear SignatureDateFees and PaymentI 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 *Clear Signature(Parent or Guardian, if Minor)DateI 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 *Clear Signature(Parent or Guardian, if Minor)DateAuthorization for Release of Information to Family and/or FriendsPatient NameDate of BirthOral Facial Surgery Institute, Inc. is authorized to release protected health information about the above-named patient to the entities named below.Authorization for Release of InformationMedical InformationResults from Tests or X-raysFinancial InformationFamily/Friend NamePhoneFamily/Friend NamePhonePreviousWebsiteSubmit