Oral Surgery Patient Registration Form

Patient Information

• Full Legal Name: ________________________
• Date of Birth: //____
• Social Security Number: --___
• Gender: □ Male □ Female □ Other
• Marital Status: □ Single □ Married □ Divorced □ Widowed

Contact Information

• Home Address: ________________________
• City/State/ZIP: ________________________
• Mobile Phone: ()-______
• Home Phone: ()-______
• Email: ________________________
• Preferred Contact Method: □ Phone □ Email □ Text

Emergency Contact

• Name: ________________________
• Relationship: ________________________
• Phone: ()-______

Insurance Information

Primary Insurance

• Insurance Company: ________________________
• Policy Holder's Name: ________________________
• Policy Holder's DOB: //____
• Member ID: ________________________
• Group Number: ________________________

Medical History

Current Medical Conditions (check all that apply)

□ Heart Disease □ Diabetes □ High Blood Pressure □ Bleeding Disorders □ Arthritis □ Cancer □ Other: ________________________

Current Medications

Allergies

□ Latex □ Penicillin □ Local Anesthetics □ Other: ________________

Dental History

• Last Dental Visit: //____
• Reason for Today's Visit: ________________________
• Are you experiencing pain? □ Yes □ No
• Pain Level (1-10): ___

Consent

I certify that the information provided is accurate and complete to the best of my knowledge.

Signature: ________________________ Date: //____