Online Patient Registration

The Center for Oral and Maxillofacial Surgery is pleased to offer our patients a convenient online pre-regisration service.

We want your personal information to remain as secure as possible; our business depends on it. We use encryption practices to help insure the integrity and privacy of the personal information and/or health-related personal information you provide to us. As an added security precaution, all personal information and/or health-related personal information are kept on servers with firewalls that meet or exceed industry standards to prevent intruders from gaining access. Although we make every reasonable effort to protect personal information and health-related personal information from loss, misuse, or alteration by third parties, you should be aware that there is always some risk involved in transmitting information via the Internet and that hackers or thieves do find ways to thwart security systems.

---

PATIENT INFORMATION

Date:
Name:
SS#
Birthdate:
Sex:	Male Female
Local Address:
City:
State:	Zip:
Home Phone:
Day Phone:
Email:
Marital Status:	Single Married Widowed Separated Divorced
Student Status:	N/A Full Time Part Time
Smoker:	Yes No
Veteran:	Yes No
Primary Care Provider:

*Fill in below if applicable

*Secondary Billing Address:
*City:
*State:	Zip:
*Home Phone:
Primary Employer:
Address:
City:
State:	Zip:
Work Phone:

*Fill in below if applicable

*Secondary Employer:
*Address:
*City:
*State:	Zip:
*Work Phone:

---

RESPONSIBLE PARTY INFORMATION (if different than above):

Name:
SS#
Birthdate:
Sex:	Male Female
Local Address:
City:
State:	Zip:
Home Phone:
Day Phone:
Email:
Marital Status:	Single Married Widowed Separated Divorced
Student Status:	N/A Full Time Part Time
Smoker:	Yes No
Veteran:	Yes No
Primary Care Provider:

*Fill in below if applicable

*Secondary Billing Address:
*City:
*State:	Zip:
*Home Phone:
Relationship to Patient:

---

PRIMARY INSURANCE:

Name of Insurance Company:
Name of Insured:
Address of Insurance Company:
City:
State:	Zip:
Phone:
Relationship to Patient:
Policy #
Group #
Copay Amount:
Deductible:
Effective Date:
Expiration Date:

---

SECONDARY INSURANCE (if applicable):

Name of Insurance Company:
Name of Insured:
Address of Insurance Company:
City:
State:	Zip:
Phone:
Relationship to Patient:
Policy #
Group #
Copay Amount:
Deductible:
Effective Date:
Expiration Date:

---

DENTAL INSURANCE:

Dental Insurance:
Policy #
Group #
Address of Insurance Company:
City:
State:	Zip:
Patient Email:

Consent

I hereby authorize and consent to examinations, treatments, release of medical information to my insurance company(ies), claim, representatives, adjustor, other physicians and/or attorney rendered by Center For Oral And Maxillofacial Surgery. I hereby assign all payments for medical services rendered to CFOMS.

I acknowledge that I have received CFOMS Privacy Policies and further acknowledge that some of my demographic information may be stored centrally at University Health Information Enterprise. (University Hospital)

Signature of Patient/Guardian:
Date:

---

GENERAL DENTAL & HEALTH CARE:

Physician:
City:
State	Zip:
Phone:
Dentist:
City:
State:	>    Zip:
Phone:
Orthodontist:
City:
State:	Zip:
Phone:

Reason for this visit:

General Health:                Good
Fair
Poor

Are you under care of a Physician?                Yes
No

Medications:

Allergies:

Serious Illness:

Any adverse reaction to anesthisia?                Yes
No

Have you ever had any of the following?

1)	Heart Disease
	Murmur, MVP, Valve Rep.	Yes No
	High Blood Pressure	Yes No
	Rheumatic Fever	Yes No
	Heart Attack	Yes No
	Stroke	Yes No
2)	Lung Disease
	Asthma / Emphysema	Yes No
	Bronchitis	Yes No
	Tuberculosis	Yes No
3)	Liver Disease
	Hepatitis	Yes No
4)	Kidney Disease	Yes No
5)	Diabetes	Yes No
6)	Hip Replacement	Yes No
7)	Bleeding Tendencies	Yes No
8)	Seizures	Yes No
9)	Malignant Hyperthermia	Yes No
10)	Have you ever taken:
	Blood Thinners	Yes No
	Steroids	Yes No
	Digitalis	Yes No
	Nitroglycerin	Yes No
11)	Are you pregnant?	Yes No

Notes: