Patient Registration - FishHawk Oral & Facial Surgery

Patient Registration Form

Patient Information

Prefix

Sex

First Name

Middle Initial

Last Name

Date Of Birth

Age

Social Security Number

Email Address

Mailing Address

Apt.

City

State

Zip

Phone Number

Cell Phone

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Referred By First Name

Referred By Last Name

Dentist First Name

Dentist Last Name

Orthodontist First Name

Orthodontist Last Name

Medical Doctor First Name

Medical Doctor Last Name

Preferred Pharmacy

Pharmacy Phone

Driver's License Number

Nearest Relative Not Living With You

Relative Phone Number

Employer Business Name

Employer Phone

Personal Payment Type

Emergency Contact Information

Emergency Contact

Emergency Contact Phone

Relation To Patient

Who Will Be Responsible For Your Account?

If Other Please List and Explain

Responsible Party First Name

Responsible Party Last Name

Responsible Party Date Of Birth

Responsible Party Age

Responsible Party Social Security Number

Responsible Party Home Phone

Responsible Party Cell Phone

Responsible Party Email

Responsible Party Driver's License Number

Responsible Party Address

Responsible Party Apt.

Responsible Party City

Responsible Party State

Responsible Party Zip

Responsible Party Employer

Responsible Party Business Phone

Spouse or Guarantor Information

Guarantor First Name

Guarantor Last Name

Guarantor Relation

Guarantor Phone Number

Guarantor Birth Date

Guarantor Social Security Number

Guarantor Address

Guarantor Apt.

Guarantor City

Guarantor State

Guarantor Zip

Guarantor Employer

Guarantor Employer Phone Number

General Insurance Information

Patient Marital Status

Patient Employed

Do You Belong To A PPO Or HMO?

Student Information

Are You A Student?

School Name

School Address

School City

School State

School Zip

Primary Dental Insurance Company Information

Employer

Business Address

City

State

Zip

Business Telephone

Plan Name

Insurance Company Name

Policy I.D. Number

Insurance Company Address

Ins. Co. City

Ins. Co. State

Ins. Co. Zip

Ins. Co. Tel.

Group Name

Group Number

Insured Party First Name

Insured Party Last Name

Relation

Birth Date

Insured Party Sex

Insured Party Social Security Number

Insured Party Phone

Insured Party Address

Insured Party City

Insured Party State

Insured Party Zip

Primary Medical Insurance Company

Employer

Business Address

City

State

Zip

Business Telephone

Plan Name

Insurance Company Name

Policy I.D. Number

Insurance Company Address

Ins. Co. City

Ins. Co. State

Ins. Co. Zip

Ins. Co. Tel.

Group Name

Group Number

Insured Party First Name

Insured Party Last Name

Relation

Birth Date

Insured Party Sex

Insured Party Social Security

Insured Party Phone

Insured Party Address

Insured Party City

Insured Party State

Insured Party Zip

Secondary Dental Insurance Company (optional)

Employer

Business Address

City

State

Zip

Business Telephone

Plan Name

Insurance Company Name

Policy I.D. Number

Insurance Company Address

City

State

Zip

Insurance Company Telephone

Group Name

Group Number

Insured Party First Name

Insured Party Last Name

Insured Party Relation

Insured Party Birth Date

Insured Party Sex

Insured Party Social Security Number

Insured Party Phone

Insured Party Address

Insured Party City

Insured Party State

Insured Party Zip

Secondary Medical Insurance Company (optional)

Employer

Business Address

City

State

Zip

Business Telephone

Plan Name

Insurance Company Name

Policy I.D. Number

Insurance Company Address

City

State

Zip

Insurance Company Telephone

Group Name

Group Number

Insured Party First Name

Insured Party Last Name

Insured Party Relation

Insured Party Birth Date

Insured Party Sex

Insured Party Social Security Number

Insured Party Phone

Insured Party Street Address

City

State

Zip

Health History

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications 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?

Height

Weight

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Have you had any illness, operation or been hospitalized in the past five years?

Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Do you have a prosthetic joint / implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia or IV sedation?

Have you, or a family member, had any unusual or serious reactions to general anesthesia or IV sedation?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Health History Continued

Do you currently have or have ever had:

Rheumatic Fever

Damaged heart valves / mitral valve prolapse

Heart murmur

High Blood Pressure

Low Blood Pressure

Chest pain / angina

Heart Attack(s)

Irregular heart beat

Cardiac pacemaker

Heart Surgery

Pneumonia, bronchitis or chronic cough

Asthma

Hay fever / sinus problems

Snoring

Sleep Apnea / CPAP

Difficult breathing / other lung trouble

Tuberculosis

Emphysema

Do you smoke or vape?

If so, how much a day?

Do you use chewing tobacco?

Alcohol intake?

If so, drinks per day

Drinks per week

Blood Transfusion

Blood disorder such as anemia

Bruise Easily

Bleeding tendency / abnormal bleed

Hepatitis, jaundice, or liver disease

Infectious mononucleosis

Gallbladder trouble

Fainting spells

Convulsions / epilepsy

Stroke

Thyroid trouble

Diabetes

Low blood sugar

Kidney trouble

High Cholesterol

Are you on dialysis?

Swollen ankles, arthritis or joint disease

Osteoporosis / osteopenia

Osteonecrosis

Stomach ulcers / acid reflux

COVID-19

Contagious diseases

Sexually transmitted diseases

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

Autoimmune disease?

Delay in healing

A tumor or growth

Cancer / radiation therapy / chemotherapy?

Chronic fatigue / night sweats

Are you on a diet?

Is there a history / treatment for an alcohol use disorder

Is there a history / treatment for a marijuana or substance use disorder?

Contact lenses

Eye disease / glaucoma

Mental health problems / anxiety / depression

A removable dental appliance

Pain and clicking of jaws when eating

Medications / Allergies

Medications you are now taking:

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Xarelto, Eliquis, Fish oil)

Have you ever taken diet pills including GLP-1’s for diabetes or weight loss (Trulicity, Ozempic, Byetta, Victoza, Rybelsus, Mounjaro, Wegovy, Saxenda etc)?

Any natural product, herbal supplement or homeopathic remedy

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years?

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis? If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Treating doctor first name

Treating doctor last name

Medications

Please list any medications you are taking.

Medication #1

Medication #1 Dosage

Medication #1 Frequency

Medication #2

Medication #2 Dosage

Medication #2 Frequency

16132 Churchview Drive, Suite 101 Lithia, FL 33547

(813) 687-5257

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