New Patient Registration Asset 18 New Patient Registration Asset 22 Make An Appointment Asset 23 Referring Doctor Step 1 of 7 - Patient Information 14% PATIENT INFORMATIONName(Required) First Middle Last Cellphone #(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code SS#Date of birth Month Day Year AgeSexFemaleMaleUndefinedMarital StatusSingleMarriedDivorceWidowEmployerOccupationFull Time Student?YesNoEmployer AddressHome phone #Work phone #ExtEmail INSURANCE INFORMATION (DENTAL)Responsible Person(Required) First Middle Last DOBAddress(Required) Street Address City State / Province / Region ZIP / Postal Code Phone Number(Required)Work Telephone #Relationship to patientSS#EmployerPositionEmployer's Address Street Address City State / Province / Region ZIP / Postal Code InsuranceMember ID #Insurance Contact #Group # SECONDARY INSURANCE INFORMATION (MEDICAL)Responsible Person First Middle Last DOBAddress Street Address City State / Province / Region ZIP / Postal Code Phone NumberWork Telephone #Relationship to patientSS#EmployerPositionEmployer's Address Street Address City State / Province / Region ZIP / Postal Code InsuranceMember ID #Insurance Contact #Group # When did the patient last consult a physician?Physician's nameReasonFamily dentist's nameWhen was the patient last hospitalized?ReasonEMERGENCY CONTACT (Please list nearest relative or friend)Name(Required) First Middle Last Home telephone(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code EmployerWork telephone #(Required)Who can we thank for referring you to our office?Name of your pharmacy?Tel # Contract to pay for medical servicesIn consideration of professional services provided to the above patient, I/we agree to pay your customary charge for these services in full, at the time of service, unless other arrangements are made with Sonoma Oral and Facial Surgery, P.L.L.C. I/we authorize Sonoma Oral and Facial Surgery, P.L.L.C. to receive assignment of insurance payments. If the customary charges are more than the benefits allowed under the responsible party's insurance plan, I/we agree to pay the difference. I understand that a finance charge of 1.5% monthly (18% APR) will be added to my outstanding account balance after 60 days. Any balance over 120 days, may be turned over to an outside collection agency. I agree to pay all finance charges, collection cost, attorneys fees, and any other cost that may be incurred to enforce collection of any amount outstanding. Any bank returned checks will be subject to a return check fee as well as any other cost that may be incurred from the financial institution.PRIVACY OF INFORMATION AND AUTHORIZATION TO RELEASE INFORMATION. It is the policy of Sonoma Oral and Facial Surgery, P.L.L.C. to maintain the privacy of all patient transactions. Sonoma Oral and Facial Surgery, P.L.L.C. is hereby authorized to release any medical or incidental information that may be necessary for either medical care or in processing requests for financial benefit. A copy of our Privacy Policy is available for your review. LEGAL RESPONSIBLE PARTY. If the patient is a minor or under custodial care, the below responsible party represents that they are legally authorized to obtain medical services for the patient. MEDICARE.Sonoma Oral and Facial Surgery, P.L.L.C. is not a participating provider under the Medicare program. Medicare patients are personally responsible for payment of services received. CONSENT FOR LABORATORY TESTING. In the event that any of the office staff of Sonoma Oral and Facial Surgery, P.L.L.C. is injured while performing patient treatment (i.e. needle stick, puncture wound, etc.), Sonoma Oral and Facial Surgery, P.L.L.C. has my full consent to draw blood for the purpose of laboratory testing. This will ensure the safety of all parties who are concerned and involved. Patient's Signature/ Responsible PartyDate Month Day Year PLEASE ANSWER ALL QUESTIONS BY CHOOSING YES (Y) OR NO (N) Has there been any change in your health within the last year?YesNoAre you now under the care of a physician?YesNoHas there been any change in your health within the last year? (If yes)Have you had any serious illness or operations?YesNoHave you been hospitalized in the past 5 years?YesNoHave you been hospitalized in the past 5 years? (If yes explain here)Do you have, or have you had heart problems? a. murmur or heart valve defectYesNob.Rheumatic fever or Rheumatic heart diseaseYesNoc. Heart valve replacementYesNod. Congenital heart defect or problemsYesNoe. Do you have a pacemakerYesNof. Heart attackYesNog. High blood pressureYesNoh. Low blood pressureYesNoi. Irregular or rapid heart beatYesNoj. Chest painsYesNok. Shortness of breathYesNol. Swollen ankles or handsYesNom. Artificial joints or prostheticsYesNoDo you have, or have you had lung problems? a. AsthmaYesNob. Bronchitis, Tuberculosis, or EmphysemaYesNoc. Other lung problemsYesNoPlease explain other lung problemsDo you have, or have you had liver problems? a. Hepatitis or yellow jaundiceYesNob. Other liver problemsYesNoPlease explain other liver problemsDo you have, or have you had kidney problems? a. Frequent kidney infectionsYesNob. Urinary tract infections or burning during urinationYesNoc. Frequent urination, or blood in the urineYesNod. Other kidney problemsYesNoPlease explain other kidney problemsDo you have, or have you had blood problems? a. AnemiaYesNob. Bleeding problemsYesNoc. Bruise easilyYesNo Do you have, or have you had stomach/intestinal problems? a. Ulcers, blood in stool, black stool, vomiting bloodYesNob. Other problems, please explain:Do you have, or have you had endocrine problems? a. Thyroid problemsYesNob. Cortisone or steroid treatmentsYesNoc. PheochromocytomaYesNoHave you been diagnosed with glaucoma Have you been diagnosed with glaucomaYesNoHave you experienced tonsillitisYesNoSinus trouble, hay fever, hives or skin rashYesNoFainting spells, seizures, or epilepsyYesNoHave you had, or do you have serious viral illnessYesNoHypoglycemia or low blood sugarYesNoDiabetes or high blood sugarYesNoPersistent cough or cough up bloodYesNoStroke?YesNoPlease explain and when you had strokeSexually transmitted disease or AIDS/HIV?YesNoDate diagnosed and treated for AIDS/HIV?Do you have an autoimmune disadvantage or disorderYesNoHave you had abnormal bleeding or any problem associated with previous tooth removal or oral surgeryYesNoHave you had any head, neck or jaw injuriesYesNoHave you experienced any problems in your jaw, such asa. clickingYesNob. pain in the joint, ear or side of faceYesNoc. difficulty opening or closing your mouth or chewingYesNoPlease list any other diseases, illnesses or health problems not listed abovePlease select any of the following drugs you are currently taking: Aspirin Birth control Antihistamines Thyroid medicine Digitalis, Nitroglycerin, or other heart medication Antibiotic or sulfa drugs Blood pressure medicine Tranquilizers or sedatives Insulin or diabetes drugs Anticoagulants (blood thinners) Cortisone (steroids Antidepressants List any other medications you are currently taking or that you have taken within the past month.List all surgeries, x-rays or radiation treatment for a tumor, growth, or other conditinon:Are you allergic to or have you had a bad reaction to any of the following drugs:Local anestheticsYesNoPenicillin or other antibioticsYesNoAspirinYesNoBarbiturates or sleeping pillsYesNoIodineYesNoCodeine or other narcoticsYesNoSulfa drugsYesNoSteroidsYesNoPain medicationYesNoValium, Demerol or BrevitalYesNoOthersDo you snore or have sleep apnea?YesNoDo you smoke?YesNoIf so, how frequently?Do you use smokeless tobacco?YesNoFor how long?WOMEN: Are you or might you be pregnant?YesNoSignature of Patient, Parent or GuardianDate Month Day Year Signature of DoctorDate Month Day Year Δ
