Demographic Information

PATIENT INFORMATION
Name

 


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.

In case of emergency, please contact*

Emergency Tel* / Relation

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT:

If Other, give name & phone number

Insurance Information

PRIMARY DENTAL INSURANCE COMPANY:
Ins. Co. Name

I.D. # / Cert. #

Group # / Contract

Policy Holder

Policy Holder's DOB

SECONDARY DENTAL INSURANCE COMPANY:
Ins. Co. Name

I.D. # / Cert. #

Group # / Contract

Policy Holder

Policy Holder's DOB

CANADIAN MEDICAL INSURANCE:
Province* / Health Care #*

Health History

HEALTH HISTORY:
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

Health History Part 2

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE:
Rheumatic fever?
YesNo

Damaged heart valves / artificial valves?
YesNo

Heart murmur?
YesNo

High blood pressure?
YesNo

Low blood pressure?
YesNo

Chest pain / angina?
YesNo

Heart attack(s)?
YesNo

Irregular heart beat?
YesNo

Cardiac pacemaker?
YesNo

Heart surgery?
YesNo

Chronic respiratory / lung conditions?
YesNo

Asthma?
YesNo

Sleep Apnea / Snoring
YesNo

Do you smoke?
YesNo

Do you vape?
YesNo

Do you use marijuana/cannabis?
YesNo

Do you use recreational drugs?
YesNo

Do you use chewing tobacco?
YesNo

Blood disorder such as anemia/leukemia?
YesNo

Bruise easily?
YesNo

Bleeding tendency / abnormal bleed?
YesNo

Fainting spells?
YesNo

Convulsions / epilepsy?
YesNo

Stroke?
YesNo

Thyroid trouble?
YesNo

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE:
Diabetes?
YesNo

If yes: on insulin?
YesNo

Low blood sugar?
YesNo

Kidney trouble?
YesNo

Are you on dialysis?
YesNo

High cholesterol?
YesNo

Arthritis / joint disease?
YesNo

Osteoporosis / osteopenia?
YesNo

Gastrointestinal issues (acid reflux, ulcers, inflamatory bowel disease)?
YesNo

Contagious diseases?
YesNo

If yes: please list?

Problems with the immune system? Possibly from medication / surgery, etc?
YesNo

Delay in healing?
YesNo

A tumor or growth?
YesNo

Cancer / radiation therapy /chemotherapy?
YesNo

Chronic fatigue / night sweats?
YesNo

Are you on a diet?
YesNo

A history of alcohol abuse?
YesNo

Contact lenses?
YesNo

Eye disease / glaucoma?
YesNo

Mental health problems / anxiety / depression?
YesNo

Behavioural / cognitive / developmental disorder?
YesNo

Is there a family history of:
CancerDiabetesHeart diseaseAnesthesia problems

Please elaborate on your health history if applicable:

WOMEN ONLY:
Is there a possibility of pregnancy?

Expected delivery date

Are you nursing?

Medications / Allergies

ARE YOU NOW TAKING:
Blood thinners?
YesNo

Any herbal supplements or homeopathic remedies?
YesNo

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphos-phonates in the past 12 years?
YesNo

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis.
YesNo

Have you been advised to avoid NSAIDs (such as ibuprofen)?
YesNo

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone?

Suboxone?

Oxycodone?

Fentanyl?

Other

ARE YOU ALLERGIC TO, OR HAD A REACTION TO:
Local anesthetic (freezing)?
YesNo

Penicillin / amoxicillin?
YesNo

Sulfa Drugs?
YesNo

Clindamycin?
YesNo

Aspirin / ibuprofen?
YesNo

Other antibiotics?
YesNo

Codeine or other narcotics?
YesNo

Latex?
YesNo

Please list any other allergies:

Are you taking any kind of medication?
YesNo

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:
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

Accident History
Is this visit related to an accident?
YesNo

If Yes, what type of accident?
AutomobileWork relatedOther

Date of Injury

Insurance company handling the claim / Claim #

Name of attorney / adjustor

Telephone number

Verification

VERIFICATION, FEES & PAYMENT, AND AUTHORIZATION
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.

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)