GAOC Patient Information form

Please fill out the registration form to the best of your knowledge.
All patient information is confidential.

PATIENT

Patient First Name:

M.I.

Patient Last Name:

Date of Birth (M/D/Y):

Age:

Sex: male female

Marital status:

Occupation:

Street:

City:

Zip:

Home Tel:

Bus. Tel:

Email Address:

Dentist:

Orthodontist:

Physician:

Referred By:

Have you ever been a patient in our practice: Yes No

Method of Personal Payment: Cash Check Credit Card

ACCOUNT

Who will be responsible for your account? Self Spouse Parent Other
Name:
Social Security:
Home Tel:
Street:
City:	State:		Zip:
Employer:		Tel:

HEALTH HISTORY

Please fill out the health history to the best of your knowledge
All patient information is confidential

Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your body. Health problems that you may have or medication 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.

MEDICATION

Are You Now Taking...	Yes	No

Any kind of medicine, drugs, or pills
Anticoagulants
Tranquilizers
Please list any other medications you are taking:

ALLERGIES

WOMEN

FAMILY HISTORY

Is there a family history of:	Yes	No
Cancer
Diabetes
Heart Disease
Anesthetic Problems

IN CASE OF EMERGENCY, CONTACT:

Name:

Telephone#:

Work#: