New Patient Registration Form Asset 18 New Patient Registration Asset 22 Make An Appointment Asset 23 Referring Doctor Patient Information Prefix Mr. Mrs. Ms. Dr. First Name Middle Initial Last Name Nickname Sex Male Female Birthdate Age Soc. Sec # Email Address Home Tel Cell # Have you ever been a patient of our practice? Yes No Dentist Medical Doctor Referred By Driver's Lic. # Nearest relative not living with you Tel. Employer Bus. Tel. Who will be responsible for your account? Self Spouse Father Mother Other First Name Last Name S.S. # Birthdate Age Tel Address Bus. Tel. Employer Spouse or other guarantor information (if different from above) First Name Last Name Relation S.S # Birthdate Address Tel Employer Bus. Tel. INSURANCE INFORMATION Student Full Time Part Time Not Status Married Divorced Legally Separated Widow Single Employed Full Time Part Time Retired Not School Name Address Do you belong to PPO or HMO? Yes No Primary Dental Insurance Company Employer Insurance Company Name Address Group # Tel Policy # Insured Policy Holder Relation Birthdate ID # Primary Medical Insurance Company Employer Insurance Company Name Address Group # Tel Policy # Insured Policy Holder Relation Birthdate ID # Medication- Are you now taking or have you taken. Any kind of medication, drug, pills? Yes No Blood thinners, (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)? Yes No Have you ever taken diet pills? Yes No Any natural or herbal product, supplement, or homeopathic remedy? Yes No Any bone density medications / Bisphosphonates (Aredia , Zometa , Fosamax, Actonel)? Yes No Have you ever taken tranquilizers, sleeping pills, anti-depressants and / or narcotics on a reqular basis? Yes No Please list any medications you are currently taking: Allergies - Are you allergic to or have you had a reaction to…. Local anesthetic (numbing med) Yes No Penicillin Yes No Other Antibiotics Yes No Sulfa Drugs Yes No Aspirin Yes No Sodium Pentothal, Valium, or other tranquilizers Yes No Codeine or other narcotics Yes No Other Medications Yes No Latex Yes No Soy Yes No Eggs / Yolk Yes No Sulfites Yes No Please list any allergies other than drug allergies: To our patients: Although oral surgeons primarily treat the area in and around your mouth, various health problems and medications can have an important interrelationship with the care you will receive. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. Are you in good health? Yes No Height Weight Have there been any changes in your general health in the recent years? Yes No Are you under the care of a physician? Yes No Date of last visit: Have you had any serious illness, operation, or been hospitalized in the past five years? Yes No Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth? Yes No Do you have a prosthetic joint/implant? Yes No Have you had a heart valve replacement or vascular graft? Yes No Have you had or do you currently have... Rheumatic Fever Yes No Damaged heart valves / mitral valve prolapse Yes No Heart murmur Yes No High Blood Pressure Yes No Chest pain / angina Yes No Heart attack(s) Yes No Irregular Heart Beat Yes No Cardiac Pacemaker Yes No Heart Surgery Yes No COPD, Bronchitis, chronic cough Yes No Asthma Yes No High fever or sinus problems Yes No Snoring / sleep apnea Yes No Difficult breathing / other lung trouble Yes No Tuberculosis Yes No Emphysema Yes No Do you smoke Yes No Do you use chewing tobacco Yes No Blood transfusion Yes No Blood disorder, such as anemia Yes No Bruise easily Yes No Bleeding tendency / abnormal bleed Yes No Hepatitis, jaundice or liver disease Yes No Infectious mononucleosis Yes No Gallbladder trouble Yes No Fainting spells Yes No Convulsion or epilepsy Yes No Stroke Yes No Thyroid double Yes No Diabetes Yes No Low blood sugar Yes No Kidney trouble Yes No Are you in Dialysis Yes No Swollen ankles, arhtritis, or joint disease Yes No Stomach Ulcers Yes No Contagious Diseases Yes No Sexually transmitted diseases Yes No Are you immunosuppressed, possibly from transplant surgery, etc. Yes No Problems with the immune system? Instead of possibly from medication / surgery, etc. Yes No Delayed Healing Yes No Tumor or growth Yes No Radiation Therapy / chemotherapy Yes No Chronic fatigue / night sweats Yes No Are you on a diet Yes No History of drug abuse Yes No History of alcohol abuse Yes No Contact Lenses Yes No Eye disease / glaucoma Yes No Mental Health Problems Yes No Removable dental appliance Yes No Pain and clicking of jaws when eating Yes No Malignant hyperthermia Yes No IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours? Who is driving you home? Consent 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 members of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. Submit Step 1 of 5 20% Patient InformationPrefix Mr. Mrs. Ms. Dr. Name(Required) First Name M. I. Last Name Nickname Sex(Required) Male Female Birthdate(Required) Age(Required) Email(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Home TelCell #(Required)Have you ever been a patient of our practice?(Required) Yes No Dentist First Last Medical Doctor First Last Referred By First Last Driver's Lic. # Nearest relative not living with you First Last Tel.Employer Bus. Tel.Who will be responsible for your account?(Required) Self Spouse Father Mother Other Who will be responsible for your account? Name First Last Birthdate Age TelAddress Street Address City State / Province / Region ZIP / Postal Code Employer Bus. Tel.Spouse or other guarantor information (if different from above)Name First Last Relation Birthdate Address Street Address City State / Province / Region ZIP / Postal Code TelEmployer Bus. Tel. INSURANCE INFORMATIONStudent(Required) Full Time Part Time Not Status(Required) Married Divorced Legally Separated Widow Single Employed(Required) Full Time Part Time Retired Not School Name Address Street Address City State / Province / Region ZIP / Postal Code Do you belong to PPO or HMO? Yes No Primary Dental Insurance CompanyEmployer Insurance Company Name Address Group #TelPolicy #Insured Policy Holder Name Relation Birthdate ID #Primary Medical Insurance CompanyEmployer Insurance Company Name Address Group #TelPolicy #Insured Policy Holder Name Relation Birthdate ID # Medication- Are you now taking or have you taken.Any kind of medication, drug, pills?(Required) Yes No Blood thinners, (Coumadin, Plavix Aspirin, Vitamin E, Ginko Biloba)?(Required) Yes No Have you ever taken diet pills?(Required) Yes No Any natural or herbal product, supplement, or homeopathic remedy?(Required) Yes No Any bone density medications / Bisphosphonates (Aredia , Zometa , Fosamax, Actonel)?(Required) Yes No Have you ever taken tranquilizers, sleeping pills, anti-depressants and / or narcotics on a reqular basis ?(Required) Yes No Have you ever taken tranquilizers, sleeping pills, anti depressants, and / or narcotics on a reqular basis ? if so please list Please list any medications you are currently taking:(Required) Allergies - Are you allergic to or have you had a reaction to…Local anesthetic (numbing med)(Required) Yes No Penicillin(Required) Yes No Other Antibiotics(Required) Yes No Sulfa Drugs(Required) Yes No Aspirin(Required) Yes No Sodium Pentothal, Valium, or other tranquilizers(Required) Yes No Codeine or other narcotics(Required) Yes No Other Medications(Required) Yes No Latex(Required) Yes No Soy(Required) Yes No Eggs / Yolk(Required) Yes No Sulfites(Required) Yes No Please list any allergies other than drug allergies: To our patients:Although oral surgeons primarily treat the area in and around your mouth, various health problems and medications can have an important interrelationship with the care you will receive. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.Are you in good health?(Required) Yes No Height(Required) Weight(Required) Have there been any changes in your general health in the recent years?(Required) Yes No Have there been any changes in your general health in the past years? Are you under the care of a physician?(Required) Yes No If so, for what are you being treated? Date of last visit: Have you had any serious illness, operation, or been hospitalized in the past five years?(Required) Yes No If so, describe Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?(Required) Yes No If so, describe where Do you have a prosthetic joint/implant?(Required) Yes No If so, describe where Have you had a heart valve replacement or vascular graft?(Required) Yes No Have you had or do you currently have...Rheumatic Fever(Required) Yes No Damaged heart valves / mitral valve prolapse(Required) Yes No Heart murmur(Required) Yes No High Blood Pressure(Required) Yes No Chest pain / angina(Required) Yes No Heart attack(s)(Required) Yes No Irregular Heart Beat(Required) Yes No Cardiac Pacemaker(Required) Yes No Heart Surgery(Required) Yes No COPD, Bronchitis, chronic cough(Required) Yes No Asthma(Required) Yes No Hay fever or sinus problems(Required) Yes No Snoring / sleep apnea(Required) Yes No Difficult breathing / other lung trouble(Required) Yes No Tuberculosis(Required) Yes No Emphysema(Required) Yes No Do you smoke(Required) Yes No Do you use chewing tobacco(Required) Yes No Blood transfusion(Required) Yes No Blood disorder, such as anemia(Required) Yes No Bruise easily(Required) Yes No Bleeding tendency / abnormal bleed(Required) Yes No Hepatitis, jaundice or liver disease(Required) Yes No Infectious mononucleosis(Required) Yes No Gallbladder trouble(Required) Yes No Fainting spells(Required) Yes No Convulsion or epilepsy(Required) Yes No Stroke(Required) Yes No Thyroid Trouble(Required) Yes No Diabetes(Required) Yes No Low blood sugar(Required) Yes No Kidney trouble(Required) Yes No Are you in Dialysis(Required) Yes No Swollen ankles, arhtritis, or joint disease(Required) Yes No Stomach Ulcers(Required) Yes No Contagious Diseases(Required) Yes No Sexually transmitted diseases(Required) Yes No Are you immunosuppressed, possibly from transplant surgery, etc.(Required) Yes No Problems with the immune system? Instead of possibly from medication / surgery, etc.(Required) Yes No Delayed Healing(Required) Yes No Tumor or growth(Required) Yes No Radiation Therapy / chemotherapy(Required) Yes No Chronic fatigue / night sweats(Required) Yes No Are you on a diet(Required) Yes No History of drug abuse(Required) Yes No History of alcohol abuse(Required) Yes No Contact Lenses(Required) Yes No Eye disease / glaucoma(Required) Yes No Mental Health Problems(Required) Yes No Removable dental appliance(Required) Yes No Pain and clicking of jaws when eating(Required) Yes No Malignant hyperthermia(Required) Yes No IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?(Required) Yes No Who is driving you home? Consent(Required) 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 members of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.Signature(Required)EmailThis field is for validation purposes and should be left unchanged. Δ Schedule an Appointment Layton: 801-773-9790 Bountiful: 801-298-2242 Book Now New Patient Registration Bountiful Form Layton Form
