REGISTRATION & MEDICAL HISTORY FORM

PLEASE READ THIS BEFORE BEGINNING THIS FORM:

The form is going to ask for your Prescriptions -

a) Name of each Medication

b) Dose & Frequency

c) Purpose (Example: High Blood Pressure)

d) Prescribing Physician (or self)

e) Include any Supplements, Vitamins, & Over the Counter Medications
Date Completing:

MonthDayYear
Date
Patient's Name:*

PrefixFirst NameLast NameSuffix
Patient's Name:

First NameLast Name
Nickname:
Nickname:
Nickname
Sex:*

MaleFemale
Female:
Date of Birth: *

MonthDayYear
Date of Birth
DOB
Today for age calculation:

MonthDayYear
Date
Age Days: For Calculation
Age:
Have you already provided our office your address?

YESNO
Address:

Address

Street Address Line 2

CityState

Zip Code
Legal Consent: Patients under 18 cannot give consent. Other patients due to mental or other circumstances may not be capable of giving consent. For scheduling surgeries it is important to identify who we need to communicate with to coordinate care. Please call our office if you have any questions.
Is the Patient Able to Provide Legal Consent?*

YESNO
Patient is Under 18
Weight: (lb.) *
Example: 130 (Only Whole Numbers)
Height: Feet*
Example: 5 (Whole Number)
Height: Inches*
Only Whole Numbers 1 - 11
Total Inches
BMI:
Marital Status:

SingleMarriedSeparatedDivorcedWidowed
Primary Contact Method:

Mobile - CallE-mailTextLandline - Home Number
Primary Contact Number: If not already provided
This is the 1st Number we will call.
Do you have an Email Address?

YESNO
Primary Contact Email:
example@example.com
Contact for Pre-Appointment Arrangements?

PatientSpouseFamily MemberCaregiverOther

Job/School/Retired:

StudentEmployedRetiredUnemployed
School - Occupation - Employer
If Retired, Please provide your past occupation & employer
Pharmacy
All prescriptions are electronically prescribed
Do you give permission to access the pharmacy medications list?

YESNO
Prescriptions: From Pharmacy Database
We will be completing this with pharmacy prescriptions from the database.
Accommodations:

No Accommodations NeededSpecial Needs - Autism etc.Memory Issues / DementiaDevelopmental ProblemsWheel ChairHearing ProblemsWear Hearing AidsNursing Home / Assisted LivingLanguageUnable to Swallow PillsOther
Unable To Swallow Pills:
Please Provide Details
Hearing: How can we best help with your appointment?
Note any details to help have a great experience.
Special Needs: Please check all that apply

AutismNon-VerbalVerbalUnderstands & Able to CommunicateLives in a Group HomeCooperativeUnable to CooperateDowns SyndromeDevelopmental IssuesRequires Sedation for Dental AppointmentsOther
Wheel Chair:
Is the patient able to transfer to a dental chair?

Able to transfer to a dental chairUnable to transfer without assistance
Wheel Chair Additional Information
Please note any other accomodations.
Accommodations Additional Information:
Please detail ANY accommodations here.

Number for Dr. Alman to Call to Check on the Patient the Evening of Surgery or Procedure?

Main Contact (Already Provided)2nd Contact (Already Provided)Other Number
Name & Relationship to Patient
Name & Relationship to the Patient
Number to Call
Number to Call Evening of Surgery
Have you been a patient of Dr. Alman?

YESNO
Has anyone in your family been a patient of Dr. Alman?

YESNO
Family who have been patients of Dr. Alman:
Welcome back!
Who referred you to Dr. Alman?

GP (General) DentistDental Specialist (not the GP)FamilyFriendInternetMedical DoctorOther
Friends:
Name(s) of Friends who referred you to Dr. Alman:
Please provide the name & relationship so that we may thank them.
MD:
Name of Medical Doctor who referred you to Dr. Alman:
Please provide the name & contact information so that we may thank them.
General Dentist:*
We send a letter to the General Dentist for their records.
Specialist:
Dental Specialist(s):

EndodontistOrthodontistPedodontistPeriodontistProsthodontist
Name of Dental Specialist(s) who referred you to Dr. Alman:
We will keep them in the loop!
Purpose for the Appointment*

Implant - Evaluation & TreatmentExtraction(s) - Adult TeethWisdom Teeth - Teenager or Young AdultWisdom Teeth - Over 30 Years OldExtraction(s) - Baby TeethOrthodontic Evaluation - For Tooth EruptionBiopsy - Includes Evaluation for BiopsyAccident / InjuryOther
Appointment Information:
Implant Planned?
Is Implant Treatment Planned?

Implant Treatment is PlannedConsidering Implant Treatment (Not Sure)Implant Treatment is NOT Planned
CONSULTATION AND BIOPSY APPOINTMENT:

Dr. Alman has over 40 years of experience in the diagnosis and treatment of oral lesions.

Pre-Appointment:
- The referring dentist or phyisican often will often send photos and a description as to their observations. Sometimes they call Dr. Alman ahead of the appointment to dicuss the case.
- Please indicate below any details to help the office ready for your appointment. Include the location, discription, and how long the lesion has been present.
- We do allow enough time for a consultation and biopsy even if Dr. Alman may decide not to perform the biopsy. This saves the patient to need a second appointment.
Consultation and Biopsy Appointment:

Time: 30 minutes to 1 hour.

Biopsy Fees:
- Consultation Only: If a biopsy is not required or performed the consutation fee is $300-350.
- Biopsies Fees: From $450-$850. The fee will depend on the location and the complexity of the excision.
- Dr. Alman is not a Participating Provider for any insurances medical or dental insurance plans. The Fees are paid at the appointment and the staff will assist with insurance filing (except for Medicare) & the member will be reimbursed directly according to the out-of-network benefits and limitations.
- Pathology Lab & Lab Fees: If a biopsy is performed, it will be sent to Johns Hopkins Oral Pathology Lab. The head pathologist, Dr. Robert Foss, is a long time personal friend of Dr. Alman's. He personally takes care to quickly inform Dr. Alman if any biopsy has a negative diagnosis. The lab does participate with all insurance plans including Medicare. Our office will send the medical insurance information with the lab sample.
Follow-up Appointment(s):
- If biopsy is performed, a follow-up appointment will be made 10 days to 2 weeks later. This appointment is usually scheduled for 15 minutes.
- At this appointment, Dr. Alman will go over the biopsy report and give a copy to the patient for their records. Future care and follow-up will be discussed.
- There is no fee for this follow-up appointment.
Biopsy Details:
Biopsy: Details such as the Location, How Long, & Description
Location: Tongue, Roof of Mouth (Palate), Floor of Mouth, Lip Duration: How long has it been there? Description: Round, Pink etc.
Accident Date:
Accident Date:
Please Provide the Date of the Accident
Accident Details:
Where and How did the Accident Happen?
Are you in GOOD HEALTH?*

YESNO
Do you see a medical doctor for ANY reason other than routine care?*

YESNO
Your Physician's Contact Information may be needed to contact them for medical clearance or medical manaagment. If you see multiple specialists please gather their information as well for later at the end of this form add each Name, Specialty, Telephone Number, Email, and Fax Number. We don't need the address but, the City, and State is appreciated.
Has there been any changes to your general health in the last 2 years?*

YESNO
Past 2 years changes to general health.
Please describe any changes to your general health in the last 2 years.
Have you had an Illness, Operation, or been Hospitalized in the past 5 years?*

YESNO
Illness, Operation, or Hospitalization Additional Information:
Please describe the Illness, Operation, or Hospitalization including dates. You can attach any medical records later on this form.
Do you have an Upcoming (or planned) Procedure or Surgery?*

YESNO
Details for Upcoming Procedure or Surgery
Please provide details.
Allergy to ANY Antibiotics? (Examples: Penicillin, Sulfa, & Tetracycline).*

YESNO
Antibiotics Allergies: Please List which Antibiotics as well as the Reaction and Severity
Antibiotic - Reaction & Severity & Any Details
Allergy to NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Aspirin / Ibuprofen / Advil / Aleve / Motrin?*

YESNO
Allergy to NSAIDs: Aspirin / Ibuprofen / Advil / Aleve / Motrin: Reaction and Severity
Reaction & Severity & Any Details
NSAIDs: Aspirin / Ibuprofen / Advil / Aleve / Motrin*

Able to take NSAIDsPrefer to NOT have NSAIDs PrescribedUNABLE to take NSAIDs
Reason to for NSAIDs Not to Be Used:
Some medical conditions may result in NSAID avoidance. Please detail the reason(s).
Acetaminophen (Tylenol) Allergy?*

YESNO
Acetaminophen (Tylenol): Reaction and Severity*
Reaction & Severity & Any Details
Acetaminophen (Tylenol)*

Able to take TylenolPrefer to NOT take TylenolUNABLE to take Tylenol
Reason to for Acetaminophen (Tylenol) Not to Be Used:
Allergy to Any Narcotics?*

YESNO
Narcotics Allergies: Which Narcotics, Reaction and Severity*
Reaction & Severity & Any Details
Narcotics*

Able to take NarcoticsPrefer to NOT have Narcotics PrescribedUNABLE/CANNOT take Narcotics
Reason for Narcotic Avoidence:
Please note if addicted, substance abuse, caution, or personal preference.
Allergy to Sleeping Pills, Sedatives (Examples: Lunesta, Sonata, Ambien, Halcion), or Anti-Anxiety Medications (Examples: Xanax, Valium, Ativan, or Libram)?*

YESNO
Allergy to Sleeping Pills, Sedatives (Examples: Lunesta, Sonata, Ambien, Halcion), or Anti-Anxiety Medications (Examples: Xanax, Valium, Ativan, or Libram) Allergies: Medication Name, Reaction and Severity*
Medication Name Reaction & Severity & Any Details
Allergy to Local Anesthetic?*

YESNO
Allergy to Local Anesthetic: Which Anesthetics? Reaction and Severity*
Anesthetics, Reaction & Severity & Any Details
Racing Heart:
"Racing Heart" due to Epinephrine / Adrenaline Used in Local Anesthetics?*

YESNO
Other ALLERGIES: Please Check ALL that apply.*

Egg YolkSoy BeansLatex or Rubber Dams (Used in Dentistry)Adhesive TapeMetalsSulfitesNo Allergies to Egg Yolk, Soy Beans, Latex, Adhesive Tape, Metals, or Sulfites
Allergy to Egg Yolk: Reaction and Severity
Reaction & Severity & Any Details
Allergy to Soybean: Reaction & Severity
Reaction & Severity & Any Details
Lecithin Allergy?
Do you know for CERTAIN if your allergy is to Lecithin (found in Egg Yolks & Soy Beans)?

YESNO
Allergy to Latex / Rubber Dam: Reaction & Severity
Reaction & Severity & Any Details
Allergy to Adhesive Tape: Reaction & Severity
Reaction & Severity & Any Details
Allergy to Metals: Which Metals? Reaction & Severity
Which Metals? Reaction & Severity & Any Details
Allergy to Sulfites: Reaction & Severity
Reaction & Severity & Any Details
Other Allergies? (Examples: Seasonal & Foods)*

YESNO
Other Allergies: Please in provide information.
Allergy, Reaction & Severity & Any Details

	For Appointments:	Financial Contact:
Organization:
Name:
Telephone:
Email:

	Reading/Level	Last Test Date
A1C
Blood Glucose

	Smoking Details:
List Products:
How Long? Years?
How Much Per Day?
If Quit When?


Subscriber's Name:
DOB:
Sex:
Address (If Different)


Member ID:
Group #:
Insurance Name:
Claims Address:

	General Practitioner (GP)
Physician's Name:
Specialty:
Telephone:
Email:
Fax:
City, State:
Date of Last Visit:

	Main Contact	2nd Contact
Name:
Relationship:
Telephone:
Email:

	Coumadin (Warfrin) - INR Last Test Results:
Last Test Date:
INR Reading: