Orthognathic New Patient Forms PATIENT INFORMATION

  •  Yes, Send emails for appointment verification
  •  No, Thanks

Orthognathic New Patient Forms

EMPLOYMENT INFORMATION

RESPONSIBLE PARTY

DENTAL INSURANCE

  •  PPO
  •  HMO

Orthognathic New Patient Forms HEALTH HISTORY

To our patients: Although oral surgeons primarily treat the area in and around you mouth, your mouth is a 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.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

HAVE YOU HAD OR DO YOU CURRENTLY HAVE

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

MEDICATIONS

Are you now taking or have you taken

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Please list any medications, including over the counter, you are currently taking and/ or attach a list:

ALLERGIES

Are you allergic to or had a reaction to

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Is there a FAMILY HISTORY of

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

In case of emergency, contact

Women ONLY

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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.

Orthognathic New Patient Forms ORTHOGNATHIC HISTORY, SIGNS, AND SYMPTOMS

Orthognathic surgery is treatment for a medical condition. Your medical insurance plan may provide coverage for orthognathic surgery. Your surgical treatment plan and clinical records can be presented by us to your carrier in order to determine benefit coverage and medical necessity. Part of establishing medical necessity is to present details about how your jaws affect various activities in your life.

Please indicate on this questionnaire what you think applies to you. The surgical treatment coordinator will discuss these items with you during your visit.

Thank You!

EATING

  •  cuts/ tears food into small pieces
  •  avoids crunchy foods
  •  prefers softer foods
  •  none of the above

Chewing:

  •  right
  •  left
  •  n/a

Estimate how many teeth come together when chewing

  •  painful (bolus) swallowing
  •  drinks liquid with bite to ease swallowing
  •  choking episodes
  •  near choking episodes
  •  none of the above
  •  upset stomach after meals
  •  n/a
  •  daily
  •  4-5 week
  •  2-3 week
  •  2-3 month
  •  4-5 month
  •  none
  •  OTC
  •  Tums
  •  Rolaids
  •  prescription
  •  Prevacid
  •  Nexium
  •  Pepcid
  •  other
  •  difficult to bite with front teeth
  •  unable to bite with front teeth
  •  painful when biting
  •  bites cheek tissue
  •  bites tongue
  •  places food farther back in mouth
  •  sometimes gulps food
  •  foods escape mouth when chewing
  •  chews some foods a longer time
  •  jaws become tired when eating
  •  jaws become sore when eating
  •  none of the above
  •  during the night
  •  have night guard
  •  had night guard
  •  none of the above
  •  Are you a restless sleeper?
  •  Do you suspect you may have sleep apnea?
  •  Have you been diagnosed with sleep apnea?
  •  Have you ever had a sleep study?
  •  Do you snore?
  •  None of the above
  •  fine, no problems
  •  stiff, tired, sore
  •  painful
  •  dry mouth
  •  sore throat
  •  gingival bleeding when brushing
  •  headaches
  •  none of the above
  •  1-2 week
  •  3-4 week
  •  >4 week
  •  Yes
  •  No

DURING THE DAY

  •  during the day
  •  n/a
  •  headaches during the day
  •  n/a
  •  1-2 week
  •  3-4 week
  •  >4 week
  •  Yes
  •  No
  •  have/ had nasal congestion
  •  had/ have sinus infections
  •  mouth breather most of the time
  •  none of the above
  •  infrequently
  •  occasionally
  •  frequently
  •  almost all the time
  •  jaws tire when talking
  •  difficulty pronouncing some words or phrases
  •  some lisping
  •  sometime others ask me to repeat due to difficulty understanding some words or phrases
  •  none of the above
  •  popping or clicking
  •  sometimes locks, open or closed
  •  difficult to find comfortable position
  •  none of the above
  •  my jaws are like someone in my family
  •  n/a

HISTORY OF SYMPTOMS AND TREATMENT

  •  Yes
  •  No

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 staff, responsible for any errors or omissions that I have made in the completion of this form.

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Orthognathic New Patient Forms

AUTHORIZATION

I authorize my surgeon and his 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. This signature on file is my authorization for the release of information necessary to process my insurance claim if applicable. I hereby acknowledge that a copy of this office’s Notice of Privacy Practices and HIPPA regulations has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

FEES AND PAYMENTS

We make every effort to keep down the cost of your oral surgical care. We deliver the finest care at the most reasonable cost to our patients; therefore we request payment at the time service is rendered unless other arrangements have been made in advance. A parent or guardian must accompany a minor patient. For your convenience, we accept Visa, MasterCard, Discover and American Express, as well as Care Credit. An estimate of the fees for any procedure or surgery you may require will be given to you upon request after your initial visit. Our staff will work with you to maximize your insurance reimbursement for covered procedures. If you have any dental and/ or medical insurance we ask that you please complete the identifying information on this form and bring along your insurance identification cards. 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. If procedure fees remain uncollected, you will be responsible for all collection costs, attorney’s fees, and court costs.

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RELEASE OF MEDICAL RECORDS

I understand 1). That OraMax Oral Surgery has an obligation to keep my personal information, identifying information, and my records confidential. 2). that I can choose to allow OraMax Oral Surgery to release some of my personal information to certain individuals or agencies. 3). that I do not have to sign a release form. I do not have to allow OraMax Oral Surgery to share my information. Signing a release form is completely voluntary. That this release is limited to what I write below. If I would like OraMax Oral Surgery to release information about me in the future, I will need to sign another written, time-limited release. 4). that releasing information about me could give another agency or person information about my location and could confirm that I have been receiving services at OraMax Oral Surgery. 5.) that OraMax Oral Surgery and I may not be able to control what happens to my information once it has been released to the below person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

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I authorize OraMax Oral Surgery to release my treatment information and/ or x-rays to my referring dentist and/ or orthodontist.

I would like my treatment to be discussed with the following individuals:

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  •  PLEASE REVIEW YOUR FORMS ON THE NEXT PAGE AND CLICK SUBMIT TO SEND US THE FORMS. IF YOU DON'T CLICK SUBMIT THE FORM WILL NOT BE SENT TO THE OFFICE. CHECK THE BOX TO CONFIRM YOU HAVE READ THIS.

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