Registration Form | Oral & Facial Institute of Houston

Patient Full Name *

Date of Birth

Sex

Social Security No.

Address

Apt No.

City

State

Zip

Phone Number

Cell Phone Number

Email *

Referring Doctor

Emergency Contact

Phone

Full Time Student

If yes, name of college

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

Full Name

Date of Birth

Relationship to Patient

Social Security No.

Address

Apt No.

City

State

Zip

Phone Number

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 *

Date

OFFICE NOTES - Leave Blank- For Office Use Only

Medical History

Name

Height

Weight

Age

ALLERGIES & MEDICATION

Please list all known allergies

Please 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?

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

Date of Last Physical Exam

Are you now under the care of a physician?

If yes, for what condition?

Physician’s Full Name

Have you had any serious illness, operation, or hospitalization?

If yes, please explain

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?

Are you pregnant?

Are you nursing?

Are you taking birth control?

Do you wear contact lenses?

Do you have any of the following diseases or problems?

Rheumatic Heart Disease
Diabetes
Low/High Blood Pressure
Thyroid Problems
Shortness of Breath/Emphysema
Hepatitis, Jaundice, or Liver Disease
Heart Attack
Stomach Ulcers/Reflux
Heart Surgery/Valve Replacement
Immune Deficiency
Chest Pain
AIDS/HIV Positive
Heart Murmur
Arthritis or Painful Joints (Including TMJ)
Any Other Heart Trouble
Asthma or Hay Fever
Anemia or Other Blood Disorder
Respiratory Problems
Abnormal Bleeding
Sinus Trouble
Other Blood Disorder
Persistent Cough
Stroke
Tuberculosis
Frequent Mouth Sores
Tumor or Cancerous Growth
Neurologic Disorder or Epilepsy
Radiation Treatment or Chemotherapy
Anxiety or Psychiatric Conditions
Persistent Swollen Neck Glands
Fainting Spells or Seizures
Alcohol or Chemical Dependency
Kidney Trouble
Smoke or Chew Tobacco
Osteoporosis
Other condition doctor should know
Prosthetic Joint(s)

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

Signature *

Date

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

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 *

(Parent or Guardian, if Minor)

Date

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 *

(Parent or Guardian, if Minor)

Date

Authorization for Release of Information to Family and/or Friends

Patient Name

Date of Birth

Oral 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 Information

Medical Information
Results from Tests or X-rays
Financial Information

Family/Friend Name

Phone

Family/Friend Name

Phone

Please Fill in the Required Information

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

Medical History

ALLERGIES & MEDICATION

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

Privacy Practices

Fees and Payment

Authorization for Release of Information to Family and/or Friends

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

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