Gravity Form"*" indicates required fieldsPatient Information:Date* MM slash DD slash YYYY Patient Name* First Name Middle Initial Last Name DOB* MM slash DD slash YYYY SSNSexMaleFemaleEmail* Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Referring Doctor*Preferred PharmacyPhoneEmergency ContactPhonePrimary Dental Insurance:Self Pay Self PayPolicy Holder/Subscriber/Member Name*Relation*DOB* MM slash DD slash YYYY Policy Holder SSN*SexMaleFemalePhone*Employer*Insurance Company*Member ID*Subscriber Address*Secondary Dental Insurance:No Secondary Insurance No Secondary InsurancePolicy Holder/Subscriber/Member Name*Relation*DOB* MM slash DD slash YYYY Policy Holder SSN*SexMaleFemalePhone*Employer*Insurance Company*Member ID*Subscriber Address*Upload Insurance Cards:Upload Front of the Insurance Card*Max. file size: 10 MB.Upload Back of the Insurance Card*Max. file size: 10 MB.Upload Photo ID*Max. file size: 10 MB.Medical History:Have you had, or do you currently have:Difficulty breathing/ lung trouble?* Yes NoBleeding tendency/ abnormal bleeding?* Yes NoHigh blood pressure?* Yes NoHIV/AIDS?* Yes NoConvulsions/ epilepsy?* Yes NoHeart attacks?* Yes NoStroke?* Yes NoDiabetes?* Yes NoAsthma?* Yes NoSleep apnea/ CPAP?* Yes NoOsteoporosis/ Osteopenia?* Yes NoMental health / anxiety/ depression?* Yes NoCancer, radiation therapy, or chemotherapy?* Yes NoSocial History:Smoke/ Vape?* Yes NoMarijuanna or recreational drug use?* Yes NoChewing tobacco?* Yes NoAlcohol use?* Yes NoMedications and Allergies:Medications:*List all current medications.Allergies:*List all allergies.Any additional health related concerns the doctor should be made aware of?Past Procedures:Have you had any procedures or surgeries? Describe.*Have you had general anesthesia? Any complications? Describe.*Verification: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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.Signature:*Date MM slash DD slash YYYY Release of Information:This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.Signature:*Date MM slash DD slash YYYY Fees and Payments:We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. 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. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co- insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.Signature:*Date MM slash DD slash YYYY Authorization for Service:I authorize my surgeon and his / her 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 to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment.Signature:*Date MM slash DD slash YYYY Notice of Privacy Practices:I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.Signature:*Date MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.