NEW PATIENT REGISTRATION

Patient First Name

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Patient Last Name

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Preferred Name

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Who will be responsible for your Account?

Self

Spouse

Father

Mother

Other

Sex

Male

Female

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Date of Birth

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Age

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Social Security #

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Address

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City

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State

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Zip

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Home Tel. #

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Business Tel.#

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Ext.

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Cell Phone #

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Dentist

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Medical Doctor

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Referred By

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Have you ever been a patient of our practice?

Yes

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Primary Dental Insurance Company

Employer

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Ins. Co. Name

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Insurance ID #

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Address

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Insured Party

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Relation

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Sex

Male

Female

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Date of Birth

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Social Security #

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Secondary Dental Insurance Company

Employer

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Ins. Co. Name

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Insurance ID #

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Address

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Insured Party

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Relation

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Sex

Male

Female

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Date of Birth

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Social Security #

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Health History

To our patients: Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care, that you will be receiving. Thank you for answering the following questions. Your answers are for our records and will be kept confidential.

Are you allergic or sensitive to any drugs?

Yes

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Please List

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Are you taking any medications?

Yes

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Please List

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Have you ever been admited to a hospital?

Yes

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Have you had previous surgery?

Yes

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Have you ever had problems with general anesthesia?

Yes

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Have you taken bone density medications, or bisphosphonates such as Fosamax, Boniva, Actonel, Zoometa, Aredia or Reclast in the past 10 years?

Yes

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Previous treatment for cancer/radioation or chemotherapy

Yes

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Tobacco: Do you smoke?

Yes

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Chewing tobacco

Yes

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Do you drink alcohol?

Occ

Mod

Heavy

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Height

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Weight

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Approximate date of last physical exam by your physician?

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Have You Had Or Do You Currently Have...

Joint Replacement?

Yes

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Difficulty breathing/other lung problems?

Yes

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Heart Murmur?

Yes

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Bleeding Tendency?

Yes

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Rheumatic Fever?

Yes

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Irregular heart beat?

Yes

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Heart Trouble?

Yes

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High Blood Pressure?

Yes

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Cardiac Pacemaker?

Yes

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Anemia?

Yes

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Kidney Disease?

Yes

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Diabetes?

Yes

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Seizure Disorder?

Yes

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Asthma?

Yes

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Sinus Problems?

Yes

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Cancer?

Yes

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Damaged Heart Valve?

Yes

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Eye disease/glaucoma?

Yes

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Tuberculosis?

Yes

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Chest Pain?

Yes

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Immune Deficiency?

Yes

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Hepatitis?

Yes

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Chronic Cough?

Yes

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Latex Allergy?

Yes

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Notes

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Are you nursing, pregnant or trying to become pregnant?

Yes

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Do you take birth control pills?

Yes

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Fees & Payments

We make every effort to provide you with the finest surgical care and to keep down its cost. We will work with you to maximize your insurance reimbursement for covered procedures and will furnish you an estimate of charge for any procedure or surgery prior to service. Payment for services is due at the time rendered unless other arrangements have been made. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company.

This signature on file is my authorization for the release of information necessary to process my claim, I also authorize payment to this doctor named of the benefits otherwise payable to me.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

HIPAA RELEASE

All patient records are confidential. A copy of our office privacy policy is available to me upon request. If anyone may be calling on the patient’s behalf, please complete this section. If you do not wish to add anyone, please complete name & D.O.B and sign & date at the bottom of this section.

Patient Name:

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Patient D.O.B:

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give the individuals listed below permission to access all health information/records pertaining

Name

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Relation to patient

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Date

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Name

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Name

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Relation to patient

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Date

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Name

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Name

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Relation to patient

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Date

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Name

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At Peninsula Oral and Facial Surgery we think it is important to be transparent with our patients about any industry funding that our doctors receive. You can rest assured that no financial contribution from any industry partner will ever alter your care or our treatment recommendations. Pursuant with the requirements put forth by the California Medical Board any of our patients can find information about any financial support received from industry partners by using the database below. If you have any further questions about this, please do not hesitate to ask your doctor during your consultation. “The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov.”

Date

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