Step 1 of 5 20% Date General Patient InformationPatient first name*Patient middle initialPatient last name*NicknameSexMaleFemaleDate of birth* AgeSocial security numberAddressCityStateIndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipPrimary phone number*Secondary phone numberEmail Referring doctorGeneral dentistPhysicianOccupationEmployerEmployer addressName of school if the patient is over 18 years old and a full-time studentCity of schoolFamily members seen at this officeMarital statusSingleMarriedSeparatedDivorcedWidowedFINANCIALLY RESPONSIBLE PARTYPerson financially responsible for the account:SelfOtherFull name of responsible partySex of responsible partyMaleFemaleDate of birth of responsible party Social security number of responsible partyAddress of responsible partyCity of responsible partyState of responsible partyIndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of responsible partyPrimary phone number of responsible partySecondary phone number of responsible partyEmail address of responsible party Occupation of responsible partyEmployer of responsible partyEMERGENCY CONTACT:Name of emergency contactEmergency contacts relationship to patientPrimary phone number of emergency contactSecondary phone number of emergency contactEmail address of emergency contact INSURANCE INFORMATION:Primary Dental Insurance:Primary dental insurancePhone number of primary dental insuranceAddress of primary dental insuranceEmployer of primary dental insurance policyholderName of primary dental insurance policyholderDate of birth of primary dental insurance policyholder Primary dental insurance policyholders relationship to patientPolicy ID number of primary dental insuranceGroup ID number of primary dental insurance policyholderPrimary Medical Insurance:Primary medical insurancePhone number of primary medical insuranceAddress of primary medical insuranceEmployer of primary medical insurance policyholderName of primary medical insurance policyholderDate of birth of primary medical insurance policyholder Primary medical insurance policyholders relationship to patientPolicy ID number of primary medical insuranceGroup ID number of primary medical insuranceSecondary Dental Insurance:Secondary dental insurancePhone number of secondary dental insuranceAddress of secondary dental insuranceEmployer of secondary dental insurance policyholderName of secondary dental insurance policyholderDate of birth of secondary dental insurance policyholder Secondary dental insurance policyholders relationship to patientPolicy ID number of secondary dental insuranceGroup ID number of secondary dental insuranceSecondary Medical Insurance:Secondary medical insurancePhone number of secondary medical insuranceAddress of secondary medical insuranceEmployer of secondary medical insurance policyholderName of secondary medical insurance policyholderDate of birth of secondary medical insurance policyholder Secondary medical insurance policyholders relationship to patientPolicy ID number of secondary medical insuranceGroup ID number of secondary medical insurance Medical HistoryHeightWeightMEDICATIONS:Are you taking or have you taken any of the following?Blood thinnersYesNoDiet pillsYesNoBone density medications or bisphosphonatesYesNoNarcoticsYesNoSleeping pillsYesNoAntidepressantsYesNoList all current medications and dosage:ALLERGIES:Are you allergic to or have you had a reaction to:Local anesthetics or numbing medication?YesNoPenicillin or amoxicillin?YesNoOther antibiotics?YesNoAnxiety or sleeping medications?YesNoNSAIDs such as ibuprofen or aspirin?YesNoNarcotics or opiates or strong pain medications?YesNoSoy or eggs or egg yolk?YesNoOther allergies?YesNoList other allergies: Medical History (cont)What is the reason for todays visit?Are you currently under a physicians care?YesNoFor what condition are you seeing a physician?Have you ever had a serious illness or operation or hospitalization?YesNoDo you have unhealed or recurrent injuries or inflamed areas or growths or sore spots in or around your mouth?YesNoIf yes where?Have you ever had an artifical joint replacement such as knee or hip or shoulder?YesNoIf yes when?Have you ever taken bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers?YesNoPlease describeWhen was the treatment? Do you take blood thinners?YesNoList which blood thinners you are taking:Have you had problems with previous dental treatment or general anesthetic?YesNoPlease explain the problems you have had:Do you wear contact lenses?YesNoDo you have removable dental appliances?YesNoDo you wish to talk with the doctor about anything privately?YesNo Medical History (cont)Do you have or have you had any of the following diseases or problems?Damaged heart valves or artificial valves or heart murmurYesNoChest pain or angina or heart attacksYesNoIrregular heart beatYesNoCardiac pacemakerYesNoHigh or low blood pressureYesNoStrokeYesNoSinus troubleYesNoAsthma or bronchitis or chronic coughYesNoHay feverYesNoDiabetes or low blood sugarYesNoFainting spells or seizures or epilepsyYesNoArthritis or painful swollen joints including jaw joint such as TMJYesNoHepatitis or jaundice or liver diseaseYesNoStomach ulcersYesNoSnoring or sleep apneaYesNoDifficulty breathing or lung troubleYesNoThyroid problemsYesNoInfectious mononucleosisYesNoKidney trouble or dialysisYesNoImmunosuppressedYesNoDelay in healingYesNoTumor or growthYesNoNeurological disorderYesNoEye disease or glaucomaYesNoMental health problemsYesNoAbnormal bleeding or anemiaYesNoBlood transfusionYesNoMalignant hyperthermiaYesNoPain or clicking of jaws when eatingYesNoCancerYesNoRadiation to head or neck or jawYesNoChemotherapyYesNoSexually transmitted diseaseYesNoBlood-borne diseaseYesNoDrug or alcohol dependencyYesNoEmotional disorderYesNoAny other condition the doctor should know aboutYesNoIf yes please list:Smoke or chew tobaccoYesNoIf yes how much?For how long?If any boxes above are checked please explain in more detailWOMEN ONLY:Are you pregnant or trying to become pregnant?YesNoDo you have problems associated with your menstrual period?YesNoAre you nursing?YesNoAre you taking birth control pills?YesNoCONSENT FOR CARE AND TREATMENT I, the undersigned, do hereby agree and give my consent for Granger Oral Surgery & Dental Implants to provide medical/dental evaluation, care, and/or treatment to me or someone for whom I am authorized to make medical decisions. This evaluation, care, or treatment is considered medically necessary and proper in the diagnosing or treatment of his/her/my physical condition. I understand that even though I give my consent for evaluation, care, or treatment, I may refuse any of these services at any time. FINANCIAL POLICY STATEMENT At Granger Oral Surgery & Dental Implants, we make every effort to provide you with the finest care and most convenient financial options. We will work to maximize your dental benefits for covered procedures. Payment is due at the time services are rendered. As a courtesy, we will file a claim with your dental benefit plan. Please remember that dental benefits are considered a reimbursement method for patient payments and are not a substitute for services rendered. If your dental benefit plan does not pay on your claim within 30 days from the date of service, you become responsible for any outstanding balance on your account. We have opted out of the Medicare program and are not providers for Medicaid. If you have Medicare benefits, we ask that you let us know so you can sign a contract explaining in detail the terms of opt-out status. In the event that the account is not paid in accordance with the financial arrangements made at discharge or within 90 days, the account will be turned over to a collection agency. The patient or responsible party will be responsible for all processing fees and collection costs, including reasonable attorney fees, if the account is placed in the hands of a collection agency or attorney. BENEFIT ASSIGNMENT/RELEASE OF INFORMATION I hereby authorize my insurance company to release all information necessary for payment of benefits. I hereby assign payment of benefits by my insurance company to Granger Oral Surgery & Dental Implants. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY A Notice of Privacy (NP) has been made available to me by Granger Oral Surgery & Dental Implants. The Notice of Privacy describes how my health information may be used or disclosed and my rights under the Health Insurance Portability and Accountability Act (HIPAA).You may leave messages containing protected health information or finances on my voicemail:YesNoI give permission for the release of account and health information to the following individuals:strong>Name-1Relation-1Name-2Relation-2Name-3Relation-3 I further authorize Granger Oral Surgery & Dental Implants to communicate with me electronically through the email address provided. I understand that this email is not secured by encryption and therefore is not considered a secured or private communication. Granger Oral Surgery & Dental Implants will not be responsible for further disclosure of my information sent via unencrypted email.By submitting this document, I am hereby indicating that I have read and understand the above and answered the questions to the best of my ability. I understand that it is my responsibility to fill out this form correctly and completely. To falsify or omit information could seriously harm Dr. Anderson’s ability to provide care safely.