Patient Intake Form

Name

Legal Name*

Preferred Name (if different)

Sex (insurance purposes only)

Date of Birth*

Email*

Mailing Address*

Best Contact Tel* / Other Contact Tel

Have you ever been a patient of our practice?

YesNo

Dentist

Orthodontist

Medical Dr.

YesNo

Preferred Pharmacy / Tel.

Emergency Tel* / Relation

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT:

SelfSpouseFatherMotherOther

If Other, give name & phone number

Province* / Health Care #*

To our patients:Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's office visit?*

Height / Weight*

Are you in good health?

YesNo

Have there been any changes in your general health in the past year?

YesNo

Are you under the care of a physician for a specific medial condition?

YesNo

Have you had any illness, operation or been hospitalized in the past five years?

YesNo

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

YesNo

Do you have a prosthetic joint/implant?

YesNo

Have you had a heart valve replacement or vascular graft?

YesNo

Have you ever had general anesthesia?

YesNo

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

YesNo

If so, what was the reason?

If so, what was the reaction?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

YesNo

Is there a possibility of pregnancy?

Expected delivery date

Are you nursing?

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Date of Injury

Insurance company handling the claim / Claim #

Telephone number

Verification
I certify that I have read and I understood the questions above. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I will not hold my doctor, or any member of the staff at Kelowna Oral & Facial Surgery, responsible for any errors or omissions that I have made in the completion of this form.

If I have chosen to have sedation or general anesthesia as part of my surgery today, I certify that I have not had anything to eat or drink in the past 8 (eight) hours.

Fees and Payments
Payment is due in full at the time treatment is rendered. An estimate of the costs for any procedure or surgery you may require will be provided to you. If you have dental insurance we will be glad to fill out the claim forms on your behalf, and you will be reimbursed directly according to your insurance plan. If our office receives any funds from an insurance company directly, refunds will be issued to the person that paid for treatment irrespective of the name of the policy holder.

This signature on file is my authorization for the release of information necessary to process my claim.

Authorization*
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 device concerning my care.

Pharmanet Consent
I authorize my surgeon and his/her designated nursing staff to access my personal health information contained within PharmaNet for the purpose of providing therapeutic treatment or care to me, or for the purpose of monitoring drug use by me. Pharmanet is the provincial pharmacy network and database. I understand that withdrawal of this consent must be delivered in writing.

Signature of patient(Parent or Guardian if Minor)