CALL US TO SCHEDULE
AN APPOINTMENT TODAY

Main Office # (949) 347-9990

Register

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
New Patients Can Register Below
Pre-Operative Instructions | HIPPA Notice of Privacy Practices

Patient Information
Name*:
Nickname:
Sex:
Birth Date*: Age*:
Soc. Sec. #
Driver’s Lic.#:
Email Address*:
Address*:
City*: State*: Zip*:
Home Number*: Cell Number:
Have you even been a patient at our practice? YesNo
Has a family member ever been a patient of our practice? YesNo
Referred By:
Dentist:
Medical Doctor:
Orthodontist:
Nearest relative not living with you:
Relative Tel:
Employer: Bus. Tel:


Who will be responsible for your account?
Select: (If self, skip to next section)
Name:
Soc. Sec. #
Birth Date: Age:
Tel:
Address:
Employer: Bus. Tel:


Spouse or other guarantor information (if different from above)
Name: Relation:
Soc. Sec. #
Birth Date: Age:
Tel:
Address:
Employer: Bus. Tel:


Insurance Information
Student:
School Info:
Address:
Your Status:
Employed:
Do you belong to a PPO or HMO?


Primary Dental Insurance Company
Employer:
Bus. Address:
Bus. Tel: Plan:
Insurance Company Name:
Address:
Tel:
Group #: Group Name:
Insured Party: Relation:
Sex: Birth Date:
Soc. Sec. # ID #:
Address:
Tel:


Secondary Dental Insurance Company
Employer:
Bus. Address:
Bus. Tel: Plan:
Insurance Company Name:
Address:
Tel:
Group #: Group Name:
Insured Party: Relation:
Sex: Birth Date:
Soc. Sec. # ID #:
Address:
Tel:


Primary Medical Insurance Company
Employer:
Bus. Address:
Bus. Tel: Plan:
Insurance Company Name:
Address:
Tel:
Group #: Group Name:
Insured Party: Relation:
Sex: Birth Date:
Soc. Sec. # ID #:
Address:
Tel:


Secondary Medical Insurance Company
Employer:
Bus. Address:
Bus. Tel: Plan:
Insurance Company Name:
Address:
Tel:
Group #: Group Name:
Insured Party: Relation:
Sex: Birth Date:
Soc. Sec. # ID #:
Address:
Tel:


Health History
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. 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 only and will be considered confidential.
Reason for today’s office visit:

99. Are you in good health?YesNo
- Height: Weight:
100. Have there been any changes in your general health in the past year?YesNo
101. Are you under the care of a physician?YesNo
- Date of last visit:
- If so, for what are you being treated?
102. Have you had any illness, operation or been hospitalized in the past 5 years?YesNo
- If so, describe:
103. Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?YesNo
If so, describe where:
104. Do you have a prosthetic joint/implant?YesNo
If so, describe where:
105. Have you had a heart valve replacement or vascular graft?YesNo


HAVE YOU HAD OR DO YOU CURRENTLY HAVE. . .
106. Rheumatic fever?YesNo

107. Damaged heart valves / mitral valve prolapse?YesNo

108. Heart murmur?YesNo

109. High blood pressure?YesNo

110. Low blood pressure?YesNo

111. Chest pain / angina?YesNo

112. Heart attack(s)?YesNo

113. Irregular heart beat?YesNo

114. Cardiac pacemaker?YesNo

115. Heart surgery?YesNo

116. Pneumonia, bronchitis, chronic cough?YesNo

117. Asthma?YesNo

118. Hay fever / sinus problems?YesNo

119. Snoring / sleep apnea?YesNo

120. Difficult breathing / other lung trouble?YesNo

121. Tuberculosis?YesNo

122. Emphysema?YesNo

123. Do you smoke?YesNo

124. Do you use chewing tobacco?YesNo

125. Blood transfusion?YesNo

126. Blood disorder such as anemia?YesNo

127. Bruise easily?YesNo

128. Bleeding tendency / abnormal bleed?YesNo

129. Hepatitis, jaundice, or liver disease?YesNo

130. Infectious mononucleosis?YesNo

131. Gallbladder trouble?YesNo

132. Fainting spells?YesNo

133. Convulsions / epilepsy?YesNo

134. Stroke?YesNo

135. Thyroid trouble?YesNo

136. Diabetes?YesNo

137. Low blood sugar?YesNo

138. Kidney trouble?YesNo

139. Are you on dialysis?YesNo

140. Swollen ankles, arthritis or joint disease?YesNo

141. Osteoporosis / Osteopenia?YesNo

142. Osteonecrosis?YesNo

143. Stomach ulcers?YesNo

144. Contagious diseases?YesNo

145. Sexually transmitted diseases?YesNo

146. Are you immunosuppressed?
Possibly from transplant surgery, etc.YesNo

147. Problems with the immune system?
Possibly from medication / surgery, etc.YesNo

148. Delay in healing?YesNo

149. A tumor or growth?YesNo

150. Cancer / radiation therapy chemotherapy?YesNo

151. Chronic fatigue / night sweats?YesNo

152. Are you on a diet?YesNo

153. A history of drug abuse?YesNo

154. A history of alcohol abuse?YesNo

155. Contact lenses?YesNo

156. Eye disease / glaucoma?YesNo

157. Mental health problems?YesNo

158. A removable dental appliance?YesNo

159. Pain and clicking of jaws when eating?YesNo

160. Have you, or a family member, had any unusual or serious reactions to general anesthesia?YesNo

Please Note: All numbering is not sequential.


MEDICATION – Are you now taking. . .

201. Any kind of medication, drug, pills?YesNo

202. Blood thinners (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)?YesNo

203. Have you ever taken diet pills?YesNo

204. Any natural product, herbal supplement or homeopathic remedy?YesNo

205. Have you ever taken any bone density medications / Bisphosphonates (Aredia, Zometa, Fosamax, Actonel)? YesNo

206. Have you ever taken tranquilizers, sleeping pills, anti-depressants, and / or narcotics on a regular basis?YesNo

207. Please list any medications you are currently taking:
Medication / Dosage / Frequency


ALLERGIES – Are you allergic to, or had a reaction to. . .
208. Local anesthetic (numbing med.)?YesNo

209. Penicillin?YesNo

210. Other antibiotics?YesNo

211. Sulfa Drugs?YesNo

212. Sodium pentothal, Valium, or other tranquilizers?YesNo

213. Aspirin?YesNo

214. Codeine or other narcotics?YesNo

215. Other medications?YesNo

216. Latex?YesNo

217. Soy?YesNo

218. Eggs / Yolk?YesNo

219. Sulfites?YesNo

220. Please list any allergies other than drug allergies:


IF YOU A RE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?
YesNo
Who is driving you home?


Is there any condition concerning your health that the Doctor should be told about?
YesNo

Do you wish to speak to the doctor privately about anything? YesNo


Is there a family history of:
301. Cancer: YesNo
302. Diabetes: YesNo
303. Heart Disease: YesNo
304. Anesthetic Problems: YesNo


In Case of emergency, contact:
Name:
Home Tel: Bus. Tel:


IS THIS VISIT RELATED TO AN ACCIDENT?
Automobile: YesNo
Work Related: YesNo
Other: YesNo
Date of Injury:
Insurance company handling this claim:
Claim number:
Name of Attorney / Adjuster:
Telephone Number:


This section (401–404) is for women only, men continue below.
Women, continue below when you have completed this section.
401. Is there a possibility of pregnancy? YesNo
402. Expected delivery date
403. Are you nursing? YesNo
404. Are you taking birth control pills? YesNo
Women Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.


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


Fees and Payments

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. 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 for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.


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 acquired in the course of my examination and treatment.


Notice of Privacy Practices

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

Signature of patient: (Parent or Guardian if minor)
Witness:
Doctor:
Date:

COMPANY INFO

GIVE US A CALL

Tel: (949) 347-9990 Toll Free: (877) 200-4588 Covina: (626) 966-1800 Fax: (949) 347-9991 Covina Fax: (626) 858-1788

OUR LOCATIONS

28202 Cabot Road, Suite 420
Laguna Niguel, CA. 92677

IMPORTANT LINKS


CONNECT WITH US