Date
*
Scheduled Office Location*
Midland
Odessa
General Patient Information
First name
*
Middle initial
Last name
*
Address
*
Apt
City
*
State
*
Texas
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
*
Email
*
Primary phone number
*
Self
Other
Please Name Contact*
May We Reach You by Text?*
Yes
No
Secondary phone number
*
Self
Other
Please Name Contact*
May We Reach You by Text?*
Yes
No
Date of birth
*
Age
*
Sex
*
Male
Female
Height
*
Weight
*
Social security number
*
Drivers license number
*
Employer
*
Marital status
*
Married
Single
Divorced
Widowed
Name of spouse
Emergency Contact*
Phone number of emergency contact
*
General Dentist*
Referring Dentist/Doctor
FINANCIALLY RESPONSIBLE PART
Y
(If it is NOT a parent/guardian, skip to Medical History section)
Parent or guardian name
*
Relationship to patient
*
Date of birth of financially responsible party
*
Social security number of financially responsible party
*
Address of financially responsible party
*
City of financially responsible party
*
State of financially responsible party
*
Texas
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip code of financially responsible party
*
Phone number of financially responsible party
*
Work phone number of financially responsible party
*
Employer of financially responsible party
*
ALLERGIES AND MEDICATIONS
ALLERGIES
Are you allergic to or have you ever had a bad reaction to any of the following?
Local anesthetics or numbing medication
*
Yes
No
Penicillin or Amoxicillin
*
Yes
No
Other antibiotics
*
Yes
No
If so list
*
Barbiturates or sedatives or sleeping pills
*
Yes
No
Aspirin or Ibuprofen or Advil or Motrin
*
Yes
No
Latex
*
Yes
No
Valium or Versed
*
Yes
No
Narcotics such as Demoral or Fentanyl or Codeine or Hydrocodone
*
Yes
No
Iodine
*
Yes
No
Any other allergies, please list
*
MEDICATIONS
Please list
ALL
prescription medications or nonprescription medications or hormones or vitamins or alternative or natural medications. If you do not take any medications at all answer NONE*
Have you taken any of the following AT ANY TIME?*
Select The Following Drugs You Have Used At Any Time To Treat Osteoporosis or Cancer
Fosamax
Didronel
Aredia
Boniva
Zometa
Skelid
Actonel
Reclast
Xgeva
Prolia
Bisphosphonate
Select The Following Drugs You Have Used At Any Time To Treat Autoimmune Diseases
Humira
Enbrel
Cosentyx
Orencia
Rituxan
Tysabri
Stelara
Taltz
Prednisone
Other, Please List:
MEDICAL HISTORY
Has there been any change in your health in the past year?
*
Yes
No
Have you had any serious illness or operation or hospitalization in the last five years?
*
Yes
No
If yes please explain
*
Date of last physical exam
*
Are you now under the care of a physician?
*
Yes
No
Physicians name
*
Physicians address
Condition being treated
*
Have you had any serious problems associated with any previous dental treatment?
*
Yes
No
Explain if yes
*
Do you currently or have you ever had TMJ or jaw joint problems?
Yes
No
Do you smoke?
Yes
No
If yes how many packs per day?
*
For how many years?
*
Do you use or have you ever used marijuana or methamphetamines or cocaine or crack or heroin?
*
Yes
No
If yes please clarify
*
Do you drink alcoholic beverages?
*
Yes
No
If yes how much?
*
WOMEN ONLY
Please check if any of the following apply:*
Birth Control or Hormones
Do you have problems associated with your menstrual period?
Nursing?
Pregnant? W
hat trimester?
MEN ONLY
Do you have any prostate gland problems?
ALL:
Do you have or have you ever had any of the following diseases or problems?
Rheumatic fever or rheumatic heart disease
*
Yes
No
Heart defects present from birth
*
Yes
No
Heart disease or heart attack or angina or coronary artery problems or heart murmur or stent placement or abnormal rhythm
*
Yes
No
Chest pain upon exertion
*
Yes
No
Difficulty walking up one flight of stairs without resting
*
Yes
No
Ankle swelling
*
Yes
No
Shortness of breath while lying flat or require extra pillows when sleeping
*
Yes
No
High blood pressure or hypertension
*
Yes
No
Low blood pressure or hypotension
*
Yes
No
History of stroke
*
Yes
No
Fainting spells or seizures
*
Yes
No
Tuberculosis
*
Yes
No
Persistent cough or coughing blood
*
Yes
No
Glaucoma
*
Yes
No
High thyroid or hyperthyroid
*
Yes
No
Low thyroid or hypothyroid
*
Yes
No
Stomach ulcers or GERD or acid reflux or other intestinal disorders
*
Yes
No
Hepatitis or Cirrhosis or fatty liver or other liver diseases
*
Yes
No
Kidney trouble or kidney failure or dialysis
*
Yes
No
Inflammatory rheumatism or arthritis
*
Yes
No
Immune system disorder
*
Yes
No
Blood disorders such as anemia or leukemia
*
Yes
No
Clotting disorder or abnormal bleeding associated with previous surgery or trauma or extractions
*
Yes
No
Seasonal allergies or sinus trouble
*
Yes
No
Any prosthetic or artificial joints
*
Yes
No
Emotional or psychiatric disorders
*
Yes
No
Had surgery or radiation or chemotherapy for tumor growth or cancer
*
Yes
No
Please clarify
*
Transfusion of blood or blood products
*
Yes
No
Osteoporosis
*
Yes
No
Lung disorder such as Asthma, COPD, Bronchitis, Other*
Yes
No
If other Lung Disorder, Please List*
If asthma when was your last emergency room visit?
*
Hospital admission
*
Most recent episode
*
Sleep apnea
*
Yes
No
CPAP setting
*
Diabetes
*
Yes
No
If yes what is your average morning blood sugar level?
*
When was your last hemoglobin A1C?
*
Any condition or disease not listed above that the doctor should know about?
*
Yes
No
Explain
*
HIPAA Consent Patient Information Release
I authorize Permian Basin Oral Surgery & Dental Implant Center to release my personal health information to family members or others involved in my care or assisting me with financial arrangements
*
Yes
No
These are the individuals with whom Permian Basin Oral Surgery & Dental Implant Center is allowed to share information:
Name one
Relationship one
Phone or contact information one
Name two
Relationship two
Phone or contact information two
Name three
Relationship three
Phone or contact information three
Privacy Information
Please check YES or NO for the following statements. By checking YES for the following statements, this office will leave voicemail or answering machine messages at your home, work, or emergency contact on file that may include protected health information and may be overheard by others not involved in your care.
Home callback or message?
Yes
No
Home detailed message?
Yes
No
Work callback or message?
Yes
No
Work detailed message?
Yes
No
Text callback or message?
Yes
No
Text detailed message?
Yes
No
Email callback or message?
Yes
No
Email detailed message?
Yes
No
Financial Policy
Thank you for choosing us as your oral surgery provider. We make every effort to keep down the cost of your care. You can help by supplying correct information to us in regard to your insurance policy and person responsible for the account. An estimate of charges for any procedures or surgery you may require will be given to you following the consultation.
Payment in full is expected when services are rendered. Although your insurance may assist you with partial payment of your treatment, the estimated portion that is not covered is due when services are rendered. If insurance pays less than the estimate, you will be billed for the remaining balance. If insurance payment results in a credit, a refund check will be issued.
As a courtesy to our patients, we will file your primary insurance for you. Insurance coverage varies between dental and medical and we will file the claim accordingly. Our office is an out-of-network provider with all insurance companies. Charges for services rendered are ultimately your responsibility to pay. We are not a party in your insurance policy and therefore are not liable to write off any fees or charges regardless of insurance benefits/non-covered services/usual and customary fees/or any determinations made by your insurance company.
Remember, insurance policies are to assist the patient and are not a substitute for payment. If your insurance has not paid within 60 days from the day of service, any balance will become your responsibility. We will, however, continue to work with your insurance company to ensure they process the claim.
I understand and agree that I am ultimately responsible for all fees incurred.
I agree to pay any and all unpaid balances on my account.
I understand and agree if patient is a minor/student/under the financial responsibility of their parent, the parent accompanying the patient will be responsible for the account and this office will not involve itself in divorce/separation/guardianship/decree situations.
I understand and agree that it is my responsibility to supply all current and correct primary insurance information.
I understand and agree if insurance has not paid within 60 days from the day of service, any balance will become my responsibility.
I authorize all insurance benefits to be paid to Permian Basin Oral Surgery & Dental Implant Center.
I authorize the release of my information to my insurance company to obtain reimbursement of any claim(s) or records purposes.
If payment by the insurance is made to the insured, I agree to endorse or have the insured endorse the benefits check or make immediate payment to Permian Basin Oral Surgery & Dental Implant Center.
I authorize this office to discuss my account with a spouse or parent/stepparent (if patient is not a minor but using their insurance).
I have read, understand, and agree to the above terms.
PRIMARY MEDICAL insurance company
PRIMARY MEDICAL
Insured name
PRIMARY MEDICAL
Insured employer
PRIMARY MEDICAL
Insured social security number
PRIMARY MEDICAL
Insured date of birth
PRIMARY DENTAL
insurance company
PRIMARY DENTAL Insured name
PRIMARY DENTAL
Insured employer
PRIMARY DENTAL
Insured social security number
PRIMARY DENTAL
Insured date of birth