CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #: ( Work Phone #:( Sex: Male Female Cell Phone #:( Social Security Number: Marital Status: Single Married Divorced Separated Widow Primary Language: Email Address: Patient s School Name: Full time Part time Not a Student Patient s Employer Name: Full time Part time Retired Not Employed How did you hear about our practice? Patient s General Dentist Name: General Dentist Phone #: ( Patient s Physician Name: Physician Phone #: ( Patient s Orthodontist Name (if applicable: Orthodontist Phone #: ( Has a family member ever been a patient of our practice? Yes No Emergency Contact Name: If Yes, their name: Relation to Patient: BILLING INFORMATION Phone #: ( ONLY IF PATIENT IS A MINOR (under 18 years old Father s Last Name: Street Address (if different from patient: Best Contact Phone #: ( Mother s Last Name: Social Security # (Required: Street Address (if different from patient : Best Contact Phone #: ( Social Security # (Required: INSURANCE INFORMATION In order to process your insurance claim, we MUST have a copy of all your current insurance cards. In addition, ALL of the following MUST be provided. MEDICAL INSURANCE Medical Insurance Name (if None, write None : Claims Address: Insurance Phone #: ( Policy Type: PPO HMO Medicare Indemnity Work Comp Other Policy Type: Group/Employer Individual Medical Insurance Policy/ID #: Medical Group #: Policy Holder Last Name:
Policy Holder Street Address (if different from patient: Social Security #: Policy Holder Employer: Policy Holder s Relationship to Patient: Self Spouse Parent Step-Parent Other (please explain DENTAL INSURANCE Dental Insurance Name (if None, write None : Claims Address: Insurance Phone #: ( Policy Type: PPO HMO Indemnity Discount Plan Dental Insurance Policy/ID #: Dental Group #: Policy Holder Last Name: Policy Holder Street Address (if different from patient: Social Security #: Policy Holder Employer: Policy Holder s Relationship to Patient: Self Spouse Parent Step-Parent Other (please explain ACCIDENT INFORMATION Is treatment due to an accident or injury? Yes No; If Yes please provide the following information. (If No, skip to ALL PATIENTS Describe how the injury/accident occurred: If auto accident injury; Auto Insurance Policy ID#: Accident Claim #: If work related injury; Workers Comp Claim #: Date of Accident/Injury: Agent/Adjuster Name: Phone #: ( Dates you have been unable to work: thru Do you have an attorney for this case? Yes No If yes; name: Phone #: ( ALL PATIENTS By signing below, I acknowledge the above information as being correct and agree to notify CFOMS as changes may occur. I also agree to pay any deductible, co-pay, co-insurance, or other amounts not covered by insurance. The signature below serves as a signature on file authorizing CFOMS to release any medical/dental records by law for appropriate care with other providers; to process any insurance claims; and to receive payment/ insurance benefits otherwise payable to the insured. Should I not pay the portion as stipulated above, I shall be liable for payment of any late charges or collection fees that may result. I acknowledge that I am the responsible party for this account. If patient is a minor, I certify that I am a legal guardian of the patient. Signature of Responsible Party: Printed Name: Date: OFFICE USE ONLY
TMJ Medical History Central Florida Oral & Maxillofacial Surgery, PA PATIENT S NAME: DATE: BIRTH DATE: AGE: M F MARITAL STATUS: S M W D OCCUPATION: PLEASE CHECK EACH ITEM YES OR NO AS THEY RELATE TO YOUR HEALTH *If yes, then explain on back of this page. Review of Systems (14 Systems Health History of Patient Do you now or in the past 6 months have: Yes No Yes No Yes No Headaches Nausea / Vomiting Asthma Sinus Headaches Heartburn Stroke Chest Pain Difficulty Swallowing Heart Trouble Jaw Pain Diarrhea High Blood Pressure Toothache Constipation Diabetes Sleep Apnea Arm / Calf Pain Arthritis Snoring Heart Skipping / Racing Gout Weight Loss / Gain Mood Swings Seizures Fever Significant Stress Mental Illness Fatigue (Lack of Energy Easy Bruising Cancer Double Vision Gums Bleed Easily Bleeding Disorders Blurred Vision Prolonged / Excessive Bleeding Alcoholism Ringing in Ears Joint Pain / Stiffness Lung Disease Vertigo / Dizziness Joint Swelling Tuberculosis Frequent Sore Throat Muscle Pain Phlebitis Sinus Infections Back Pain Anemia Hearing Loss Seizures Stomach Ulcer Loss of Smell Numbness / Tingling Liver Trouble Nasal Congestion Hesitant / Slurred Speech Thyroid Trouble BM/Urinary Problems Coldness of hands / feet Fibromyalgia Hay Fever / Airborne Allergies Weakness of body part Sexual Disease Hives / Eczema Trouble Walking Depression Shortness of Breath Rash / Sores / Lesions Sleep Disorder Coughing Blood Changes in a mole Serious Injuries Persistent Cough Heat / Cold Intolerance AIDS Stomach Pain Unusual Lumps or Enlarged Glands Migraines Please list all your medications (herbal, over the counter and prescribed: Allergic to any drugs? (please list List All Surgeries: FAMILY HISTORY Yes No SOCIAL HISTORY Yes No Headaches Do you smoke? Packs per day Heart Problem Do you drink alcohol? Drinks per day: Drinks per week: High Blood Pressure Recreational Drugs? None: Presently: Past: Cancer Caffeine Use: Drinks per day: Cancer Caffeine Stimulant Use: Tabs / week I certify the above medical information is correct. Signed: Date: BCENOR041
(
( ( ( (
( (