Patient Registration Form

Patient Information


1. General Information

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

Have you had or do you currently have...

2.Medication Information

Note to Women: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

3.Osteoporosis / Bone Strengthening Medication

4. Miscellaneous

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his staff, responsible for errors or omissions that I have made in the completion of this form.
RELEASE OF INFORMATION: This information includes Lab tests, X-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.