Patient Information Form

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Folsom Oral Surgery And Implant Center
Gregory G. Olsen, DDS, FICOI
Diplomate of the American Board of Oral and Maxillofacial Surgery
Diplomate of the National Dental Board of Anesthesiology

2370 E. Bidwell, Suite 130 - Folsom, CA 95630
Tel: 916-983-6637 - Fax: 916-983-6610 - www.folsomdentalimplants.com

Patient Information:

Patient Name Referred By Last Name M.I. First Name

Address Apt. #

City State Zip

Home Phone

(

)

Work Phone

(

)

Cell Phone

(

)

E-Mail

Employer Occupation How Long

Social Security # Birthdate Age Sex: Male Female

If student, school attending Full-Time Part-Time

If necessary, can you provide documentation of enrollment status? Yes No

Emergency Contact Name Home Phone #

(

)

Cell Phone #

(

)

Address City State Zip

Person Financially Responsible:

Use Patient Information

Name Last Name M.I. First Name

Address Apt. #

City State Zip

Home Phone

(

)

Work Phone

(

)

Cell Phone

(

)

E-Mail

Employer Occupation

Driver's License # Expires

Social Security # Birthdate

Spouse's Name Occupation How Long

Relation to Patient Self Spouse Father Mother Other

List name of guardian with which the patient resides

Insurance Information:

Primary Dental Insurance Company Name Subscriber's Name Subscriber's Date of Birth

Subscriber's Social Security # Subscriber's ID #

Employer Group #

Insurance Carrier Carrier Phone

(

)

Address to Mail Claims to

City State Zip

Relation to Patient Self Spouse Father Mother Other

Secondary Dental Insurance Company Name Subscriber's Name Subscriber's Date of Birth

Subscriber's Social Security # Subscriber's ID #

Employer Group #

Insurance Carrier Carrier Phone

(

)

Address to Mail Claims to

City State Zip

Relation to Patient Self Spouse Father Mother Other

Medical Insurance Company Name Subscriber's Name Subscriber's Date of Birth

Subscriber's Social Security # Subscriber's ID #

Employer Group #

Insurance Carrier Carrier Phone

(

)

Address to Mail Claims to

City State Zip

Relation to Patient Self Spouse Father Mother Other

Statement of Financial Responsibility:

I agree to be financially responsible for all services rendered by the treating dentist. A payment on account or an insurance co-payment may be due at the time services are rendered. I will be financially responsible for all charges not covered by my insurance company. I agree to pay all financial obligations in a timely fashion. I accept that all delinquent accounts will bear interest at the rate of 18% per annum (1.5% per month), but that special financial arrangements can be made in certain circumstances.

I understand that a percentage of my surgery may be covered under my dental or medical insurance plan. I understand that all efforts will be made to determine benefits and co-payment information prior to my treatment. I understand that I will be responsible for all co-payments, deductibles, and non-covered procedures on or before the day of surgery. In the event that the insurance company denies a claim after a procedure has been completed, I understand that I am responsible for the balance on the account.

We are happy to assist you in filing the necessary forms to help you receive the full benefit of your dental coverage. Insurance policies vary greatly; therefore please understand that we can only estimate your insurance coverage in good faith. The insurance relationship constitutes an agreement between the carrier, employer and the patient. As such, we can make no guarantee of the estimated coverage or insurance payment. Please know that we will do everything within reason to see that you receive the full benefits of your policy.

Assignment of Insurance Benefits: I hereby authorize and request my insurance company to pay directly to the Doctor the amount due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense. I will be responsible for payment of the difference, and if the nature of the disability be such that it is not covered by the policy, I will be responsible to Folsom Oral Surgery And Implant Center for payment of the entire bill.

Responsible Party Signature Date

Relationship to Patient

Employee Witness Date

Yearly Update:

Responsible Party Signature Date

Relationship to Patient

Employee Witness Date

Medical History:

Patient Name Date Last Name M.I. First Name

Height Weight

In the following questions, check YES or NO, whichever applies to you. Your answers are for our records only and will be considered confidential. Thank you.

1.Has there been any change in your general health within the past year?

Yes No

2.When was your last physical exam?

3.Are you now under the care of a physician?

Yes No

If yes, for what condition(s)?

4.Have you had a serious illness or operation(s)?

Yes No

If so, what was the illness or operation?

5.Have you been hospitalized or had serious illness within the past five (5) years?

Yes No

If so, what was the problem?

6.Do you have, or have you had, any of the following problems or diseases?

a.Rheumatic fever or hrheumatic heart disease

Yes No

b.Congenital heart lesions or heart murmurs

Yes No

c.Cardiovascular disease (chest pains, angina, heart attack, coronary insufficiency, coronary occlusions)

Yes No

d.Stroke, hardening of the arteries, arteriosclerosis

Yes No

e. High or Low blood pressure

Yes No

f.Bleeding problems or bruising easily

Yes No

g.Asthma

Yes No

If yes, have you required an emergency room visit for a shot or breathing treatment?

Yes No

h.Shortness of breath

Yes No

i.Tuberculosis or emphysema

Yes No

j.Persistent cough, coughing up blood

Yes No

k.Diabetes

Yes No

l.Fainting spells, seizures, dizziness

Yes No

m.Hepatitis, jaundice, or liver disease

Yes No

n.Sinus problems

Yes No

o.Hay fever

Yes No

p.Headaches

Yes No

q.High or low thyroid symptoms

Yes No

r.HIV positive, AIDS, or ARC

Yes No

s.Venereal disease (gonorrhea, syphilis)

Yes No

t.Herpes / cold sores

Yes No

u.Dry mouth, excessive thirst

Yes No

v.Glaucoma, eye disease, blurred vision

Yes No

w.Arthritis, rheumatism, joint pain, stiffness

Yes No

x.Kidney / bladder disease, difficult or frequent urination, blood in urine

Yes No

y.Stomach ulcers, problems

Yes No

z.Tumors, cancer

Yes No

aa.Anemia

Yes No

bb.Sleep apnea

Yes No

If yes, do you use CPAP?

Yes No

cc.Emotional or psychiatric problems

Yes No

7.Do you have, or have you had, any of the following?

a.Radiation treatments or chemotherapy

Yes No

b.Artificial joint(s)

Yes No

c.Prosthetic heart valve or pacemaker

Yes No

d.Blood transfusions or abnormal bleeding

Yes No

If yes, please explain?

8.Are you taking, or have you taken, the following in the last year?

a.Antibiotics or Sulfa drugs

Yes No

b.Anticoagulants or blood thinners (Coumadin / Plavix)

Yes No

c.Aspirin

Yes No

d.Digitalis

Yes No

e.Nitroglycerin

Yes No

f.Medicine for high blood pressure

Yes No

g.Cortisone or steroids

Yes No

h.Antihistamines

Yes No

i.Insulin or diabetes medications

Yes No

j.AZT or other Anti-Retroviral

Yes No

k.Fosamax, Boniva, Zometa, Aredia or any other "Bisphosphonate" drug

Yes No

If so, which drug?

Are you still taking this?

l.Tranquilizers

Yes No

m.Diet pills

Yes No

n.Natural supplements

Yes No

o.Recreational drugs

Yes No

p.LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

q.Please list any medicine, drug, food, or material that you are ALLERGIC to (e.g. latex, Penicilin, etc.)

9.Do you have any disease, condition, or problem not listed above?

Yes No

10.Have you, or any family member, had trouble with general anesthesia (i.e. malignant hyperthermia)?

Yes No

11.Do you smoke and/ or vape?

Yes No

If so, how much per day , for how many years

12. Alcohol consumed:

daily , weekly , monthly

13.Why have you come to see us today?

Women:

14.Are you pregnant?

Yes No

15.Are you breast feeding an infant?

Yes No

16.Are taking oral contraceptives (birth control pills)?

Yes No

17.Date of last menstruation cycle:

Signatures:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and / or medications.

I consent to the taking of clinical photos in the course of diagnostic and surgical procedures for use of treatment, educational, or research purposes.

I authorize the release of any medical or other information necessary to process insurance claims and I authorize payment of benefits to the treating physician / dentist for the services provided. I also request payment of government benefits (Medicare) to the treating physician / dentist.

HIPAA Compliance Statement: (found under HIPAA/Privacy Policy)

I acknowledge that I have read a copy of the office's NOTICE OF PRIVACY PRACTICES AND RIGHTS. I have read the notice and I understand my right and the office's privacy policies.

Patient refuses to sign the notice. Employee name and date:

Name Date

The patient is unable to sign the acknowledgement or is a minor. If the patient is a minor or represented by a personal representative, the authorized guardian / representative has signed below.

Patients 18 and over. "I give permission to discuss any medical information related to my treatment to the following individual(s):"

Name Relationship

Name Relationship

Patient Signature Date

Doctor's Signature Date