Oral & Maxillofacial Surgical Consultants, P.A.

Main Header

Welcome to Our Practice

Primary Medical Insurance Company

No Medical Insurance

Ins Co Name

Address

City / State / Zip

Tel.

Subscriber ID #

Group / Client #

Policy Holder

Sex

M F

Relation to Patient

Birth Date / S.S.#

Address

Same as Patient

City / State / Zip

Tel.

Employer

Bus. Tel

Primary Dental Insurance Company

No Dental Insurance

Ins Co Name

Address

City / State / Zip

Tel.

Subscriber ID #

Group / Client #

Policy Holder

Sex

M F

Relation to Patient

Birth Date / S.S.#

Address

Same as Patient

City / State / Zip

Tel.

Employer

Bus. Tel

Secondary Medical Insurance Company

Ins Co Name

Address

City / State / Zip

Tel.

Subscriber ID #

Group / Client #

Policy Holder

Sex / Relation to Patient

M F

Relation to Patient

Birth Date / S.S.#

Address

Same as Patient

City / State / Zip

Tel.

Employer

Bus. Tel

Secondary Dental Insurance Company

Ins Co Name

Address

City / State / Zip

Tel.

Subscriber ID #

Group / Client #

Policy Holder

Sex / Relation to Patient

M F

Relation to Patient

Birth Date / S.S.#

Address

Same as Patient

City / State / Zip

Tel.

Employer

Bus. Tel

Patient Disclosure Instructions

I wish to be contacted in the following manner (check all that apply):

Home

Cell

Work

May leave a message with detailed information at this number

Yes No

Signature of Patient:
(Parent or guardian if minor)

Click to Sign

Date:-------------

Authorization

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information required in the course of my examination and treatment.

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me to read. I have been given the opportunity to ask any questions I may have regarding this Notice.

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

Signature of Patient:
(Parent or guardian if minor)

Click to Sign

Date:-------------

Oral & Maxillofacial Surgical Consultants, P.A.

Medication - Are you now taking or have you taken:

No known medications

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Gingko biloba)

Yes No

Have you taken or are you currently taking diet pills?

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Any bone density medications / Bisphosphonates (Aredia, Zometa, Fosamax, Actonel, etc.)?

Yes No

Pharmacy Information

Name

Address

Phone Number

Please list all medications you are currently taking: (Include, tranquilizers, sleeping pills, anti-depressants, and/or narcotics you take on a regular basis)

Medication #1

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For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, expected delivery date?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Initials:

Click to Sign

Date:-------------

Certification

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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of Patient:
(Parent or guardian if minor)

Click to Sign

Date:-------------

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Oral & Maxillofacial Surgical Consultants, P.A.

Main Header

Welcome to Our Practice

Patient Information

Patient Information

Insurance Information

Primary Medical Insurance Company

Primary Dental Insurance Company

Secondary Medical Insurance Company

Secondary Dental Insurance Company

Patient Disclosure Instructions

Patient Disclosure Instructions

Click to Sign

Fees And Payments

Fees And Payments

Click to Sign

Authorization

Authorization

Click to Sign

Health History

Health History

Have you had, or do you currently have::

Allergies

Allergies - Are you allergic to, or had a reaction to:

Medications

Medication - Are you now taking or have you taken:

Pharmacy Information

Please list all medications you are currently taking: (Include, tranquilizers, sleeping pills, anti-depressants, and/or narcotics you take on a regular basis)

Health History (continued)

For Women Only

Click to Sign

Certification

Certification

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Oral & Maxillofacial Surgical Consultants, P.A.

Main Header

Welcome to Our Practice

Patient Information

Patient Information

Insurance Information

Primary Medical Insurance Company

Primary Dental Insurance Company

Secondary Medical Insurance Company

Secondary Dental Insurance Company

Patient Disclosure Instructions

Patient Disclosure Instructions

Click to Sign

Fees And Payments

Fees And Payments

Click to Sign

Authorization

Authorization

Click to Sign

Health History

Health History

Have you had, or do you currently have::

Allergies

Allergies - Are you allergic to, or had a reaction to:

Medications

Medication - Are you now taking or have you taken:

Pharmacy Information

Please list all medications you are currently taking: (Include, tranquilizers, sleeping pills, anti-depressants, and/or narcotics you take on a regular basis)

Health History (continued)

For Women Only

Click to Sign

Certification

Certification

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

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