Name of Spouse:

Date of Birth:

Spouse's Employer:

Business Phone #:

Address:

Is patient a student or minor?

Yes No

B. PATIENT IS MINOR OR STUDENT

Parent 1's Name:

Date of Birth:

Phone #:

Address line 1:

Address line 2:

City:

State:

Zip code:

Parent 1's Employer:

Business Phone #:

Parent 2's Name:

Date of Birth:

Phone #:

Address line 1:

Address line 2:

City:

State:

Zip code:

Parent 2's Employer:

Business Phone #:

C. Insurance Information

Medical Insurance Carrier:

Policy Holder:

ID #:

Dental Insurance Carrier:

Policy Holder:

ID #:

Secondary Medical Insurance Carrier:

Policy Holder:

ID #:

Secondary Dental Insurance Carrier:

Policy Holder:

ID #:

All services rendered are charged to the patient. Patients are required to pay for services when rendered unless other arrangements have been made in advance. I authorize NORTHERN VERMONT ORAL SURGERY (NVOS) to furnish information to insurance carriers concerning my treatment and to verify employment or insurance coverage for myself, spouse and/or dependents. I assign NVOS all payments for services rendered to me or my dependents.

I understand that I am responsible for the payment of any amount not covered by insurance. Finance charges of 1.5% per month are assessed on accounts more than 90 days past due. If legal action is necessary to collect an unpaid balance for services rendered, I will pay all collection costs, attorney fees and court costs.

Printed name:

Relationship to patient:

Signature of responsible party:

Patient Medical History

Do you have or have you ever been told you had the following?

2. Are you:

A. Currently under a doctor's care?

Yes No

Doctor's Name:

B. Pregnant, might be or trying to become pregnant?

Yes No

Due Date:

3. Are you allergic to:

C. Penicillin?

YesNo

D. Other antibiotics?

YesNo

E. Anesthetics or other drugs?

YesNo

F. Latex Rubber?

YesNo

G. Egg or Food Allergy?

YesNo

4. Do you have:

A. Shortness of breath?

YesNo

B. Swelling of the ankles?

YesNo

C. A tendency to faint?

YesNo

D. A chest cold now?

YesNo

5. Do you:

F. Chew tobacco?

YesNo

G. Wear contacts?

YesNo

H. Gag easily?

YesNo

6. Have you ever been hospitalized or had surgery?

YesNo

7. Have you ever had complications from anesthesia?

YesNo

8. Have you ever had chemotherapy or radiation therapy?

YesNo

9. Do you use alcohol or recreational drugs?

YesNo

9. Anything else we should know about?

YesNo

Are you currently taking or in the last three months have you taken any of these medications?

A. Heart Medications

Yes No

Please describe:

B. Blood pressure medications

Yes No

Please describe:

C. Diuretic (water pill)

Yes No

Please describe:

D. Steroids

Yes No

Please describe:

E. Birth control pills

Yes No

Please describe:

F. Anticoagulant (blood thinner)

Yes No

Please describe:

G. Insulin

Yes No

Please describe:

H. Sedative/Tranquilizer/Anticonvulsants

Yes No

Please describe:

I. Diet Pills

Yes No

Please describe:

J. Antibiotics

Yes No

Please describe:

K. Herbal Medications

Yes No

L. Antidepressants/Antianxiety Medications

Yes No

M. Actonel, Boniva, Fosamax or Reclast

Yes No

Please list all current medications and dose

12a. Family Physician

12b. Family Dentist

13. Person to contact in case of emergency:

Phone

Address

14. Who referred you to our office?

15. What can we do to help you?

Is there anything you would like to discuss in private with the doctor?

Yes No

Patient Registration

Patient Information

B. PATIENT IS MINOR OR STUDENT

C. Insurance Information

Patient Medical History

Do you have or have you ever been told you had the following?

2. Are you:

3. Are you allergic to:

4. Do you have:

5. Do you:

Are you currently taking or in the last three months have you taken any of these medications?