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HealtH History
TOMASETTI AND MCLAIN Oral and Maxillofacial Surgery Please Print answer all questions by circling Yes (Y) or no (n). all resPonses are kePt confidential.
Today’s Date _____/_____/_____
2. Has there been any change in your general health in the G. Insulin or Oral Anti-Diabetic drug? . Y N H. Digitalis, Inderal, Nitroglycerin or other Heart drug? . Y N I. Are you taking or have you ever taken Bisphosphonates? Date of last physical exam? ______/______/______ (Fosamax, Actonel, Boniva, Aredia, Zometa) . Y N 4. Are you now under a physician’s care for a J. Any regular medicine, herbal or vitamin supplements? 5. Have you ever had any serious illnesses, operations or
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 9. are You allergic to or have You had an adverse
reaction to:
A. Local Anesthesia (Novocaine, etc.)? . Y N 7. do You have or have You ever had:
B. Penicillin or other antibiotics? . Y N C. Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Mitral Valve Prolapse, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, G. Other allergies or reactions? Please list . Y N Palpitations, Heart Surgery, Pacemaker)? . Y N __________________________________________________ D. Lung Disease (Asthma, Emphysema, Chronic Cough, __________________________________________________ Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)? . Y N E. Seizures, Convulsions, Epilepsy, Fainting, Dizziness, How much per day?__________ How many years?__________ Psychiatric Treatment, or other Nervous Disorder? . Y N 11. Is there any past history of Alcohol or Chemical F. Bleeding Disorder, Anemia, Bleeding Tendency, Dependency or Emotional Disorder that may affect Blood Transfusion? Do you bruise easily? . Y N G. Liver Disease (Jaundice, Hepatitis)? . Y N 12. Have you had any serious problems associated with any 13. Have you or an immediate family member had any problem associated with intravenous anesthesia? . Y N 14. Do you have any other disease, condition or problem not listed above that you think the doctor N. Implants placed anywhere in your body (Heart, O. Radiation (X-ray) treatment for Cancer? . Y N 15. Do you wish to talk with the doctor privately P. Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?. Y N 16. for women onlY
A. Are you Pregnant, or is there any chance you might
R. Any disease, drug or transplant operation that has if you are using oral contraceptives, it is important
that you understand that antibiotics (and some other 8. are You using anY of the following?
medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use B. Anticoagulants (Blood Thinners)? . Y N mechanical forms of birth control for one complete C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N cycle of birth control pills after the course of D. High Blood Pressure medications? . Y N antibiotics or other medication is completed. Please consult with your physician for further guidance.
i understand the importance of a truthful health history to assist the doctor in providing the best care possible. i have had the opportunity to discuss my
health history with my doctor.
____________________________________________________________________________________________________________ ______________________ SignaTure of perSon compleTing HealTH HiSTory medical uPdate: i have read my Health History dated ____/____/____ and confirm that it adequately states past and present conditions.
____________________ __________________________________________________________________________ __________________________________________________________ ______________________ ____________________ __________________________________________________________________________ __________________________________________________________ ______________________ Patient information Sheet
TOMASETTI AND MCLAIN Oral and Maxillofacial Surgery Title: (Mr., Mrs., Ms., Dr.) First Name: _________________________M.I.: ________Last Name: ______________________________ Sex:  Male  Female Date of Birth: _____________ Age: _______ Social Security No.: __________________________ Street: _____________________________________________________________________________________________________ City: ___________________________________________________________________ State: _________ Zip: _________________ Home Tel.: (_____) _________________________________Bus. Tel.: (_____) ________________________________ Ext.: _______ Cell Phone: (_____) ___________________________________Dentist: ______________________________ Tel.: ______________ Physician: _________________________Tel.: ______________Orthodontist: __________________________ Tel.: ______________ Emergency Contact: ___________________________________________________ Tel.: (_____) ____________________________ Reason for Being Referred to Our Office: ____________________________________Referred By: ___________________________ Family Members Who Have Been Patients: _________________________________________________________________________ Student:  Full Time  Part Time  Name/Address: ____________________________________________  Married  Divorced  Legally Separated  Widow  Single Employed:  Full Time  Part Time  Retired  Not PleaSe comPlete all inSurance information
Insurance company (Dental)
Insured party/responsIble party:
Name: ______________________________________________ Name: ______________________________________________ Address:_____________________________________________ Relation to Patient:  Self  Spouse  Parent  Other ____________________________________________________ Date of Birth: _________________________________________ Phone: (_____) _______________________________________ Street: ______________________________________________ Does your plan cover:  Dental  Medical  Both City, State, Zip: _______________________________________ Group No.: _______________Group Name: _________________ Phone: (_____) _______________________________________ Insurance ID: _________________________________________ Social Security No.: ____________________________________ Employer: ___________________________________________ Insurance company (meDical)
Insured party/responsIble party:
Name: ______________________________________________ Name: ______________________________________________ Address:_____________________________________________ Relation to Patient:  Self  Spouse  Parent  Other ____________________________________________________ Date of Birth: _________________________________________ Phone.: (_____) _______________________________________ Street: ______________________________________________ Does your plan cover:  Dental  Medical  Both City, State, Zip: _______________________________________ Group No.:_______________Group Name: _________________ Phone: (_____) _______________________________________ insurance ID: _________________________________________ Employer: ___________________________________________ Social Security No.: ____________________________________ Please turn over and complete back side + Patient information Sheet
TOMASETTI AND MCLAIN Oral and Maxillofacial Surgery
If PatIent Is a MInor:
Mother's Name: _______________________________________ Father's Name ________________________________________ Address:_____________________________________________ Address: ____________________________________________ ____________________________________________________ ___________________________________________________ Tel.: (_____) __________________________________________ Tel.: (_____) _________________________________________ Work Tel.: (_____) _____________________________________ Work Tel.: (_____) _____________________________________ Cell Tel.: (_____) ______________________________________ Cell Tel.: (_____) ______________________________________ Employer ____________________________________________ Employer ____________________________________________ fees and PayMents:
We make every effort to keep down the cost of your oral and Maxillofacial surgical care. you can help by paying upon
completion of each visit. Under certain circumstances other arrangements can be made with our office manager. an esti-
mate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental
and/or medical insurance we will be glad to file the proper forms, however, it is your responsibility to provide complete
insurance information on the front of the form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is
not a substitute for payment. some companies pay fixed allowances for certain procedures and others pay a percent-
age of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid
for by your insurance company.
this signature on file is my authorization for the release of information necessary to process my claim. I hereby au-
thorize payment directly to rocky Mountain oral and Maxillofacial surgery otherwise payable to me.
signature: ______________________________________
Please brIng thIs sheet to the front desk before ProceedIng.
Tomasetti and McLain
oral & maxillofacial surgery
Notice of Privacy Practices
This noTice describes how proTecTed medical
informaTion abouT you may be used and disclosed and
how you can gain access To This informaTion. please
review iT carefully.
1. Tomasetti and McLain Oral & Maxillofacial Surgery (TMOMS) is permitted to make uses and disclosures of protected health information for treatment, payment and health care operations, as described in the following examples.
a. For treatment – We may use and disclose your health information to a healthcare provider providing treatment to you.
b. For payment – We may use and disclose your health information to obtain payment for services we provide you.
c. For health care operations – We may use and disclose your health information in connection with our health care operations. Health care operations may include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
2. TMOMS is permitted or required, under specific circumstances, to use or disclose protected health information without the individual’s written authorization. Examples of these circumstances may be as required by law or in the case of 3. Other uses and disclosures will be made only with the individual’s written authorization, and the individual may revoke such authorization.
4. TMOMS intends to engage in one or more of the following activities: a. TMOMS may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual or patient.
b. A group health plan, or health insurance issuer or HMO with respect to a group health plan, may disclose protected health information to the sponsor 5. The individual has the following rights regarding protected health information: a. The right to request restrictions on certain uses and disclosures of protected health information. TMOMS is not required to agree to a requested b. The right to receive confidential communications of protected health c. The right to inspect and copy protected health information, as provided in the d. The right to amend protected health information, as provided in the Privacy e. The right to receive an accounting of disclosures of protected health f. The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the 6. TMOMS is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.
7. TMOMS is required to abide by the terms of the Notice currently in effect.
8. TMOMS reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.
9. TMOMS will provide individuals or patients with a revised Notice by written request.
10. Individuals may complain to TMOMS and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A complaint may be filed by submitting a written request to the contact person listed below.
11. I understand that TMOMS may communicate, via email, health information with other practitioners. This could include, but is not limited to, radiographs, treatment 12. TMOMS is authorized to release any medical or financial information regarding my treatment to the following parent / persons(s) below: _______________________________________13. TMOMS’s contact person for matters relating to complaints is: This Notice is first in effect on May 1st, 2011.
I hereby acknowledge that I have reviewed a copy of TMOMS’s Notice of Privacy ____________________________________________________ ____________________________________________________ PRESCRIPTION DRUG MONITORING NOTIFICATION
By signing this form, you confirm that you have been notified that if you receive a prescription for a controlled substance (narcotic drug) from our office and fill that prescription at a pharmacy in Colorado, certain identifying prescription information, including the name of the patient, will be entered into a database maintained by Colorado’s prescription drug monitoring program. State law requires pharmacies to report information about controlled substance prescriptions filled to the prescription drug monitoring database. This database is used to help prevent inappropriate uses of controlled substances – like fraud and diversion. The prescription drug monitoring program database contains only records related to controlled substances (narcotic drugs like painkillers, muscle relaxants and steroids). It does not contain records about other prescription drugs like antibiotics, antidepressants or any other category of prescription medication. Only authorized individuals, like healthcare personnel that prescribe controlled substances and law enforcement under very limited circumstances, can access the database and only for tightly defined uses. As long as you are using controlled medications appropriately, there shouldn’t be reason for concern. If you do not want your information in the database, please ask your dentist to prescribe a non-narcotic medication for you. More information about Colorado’s prescription drug monitoring program, including copies of individual prescription drug records stored in the database, can be obtained from the Colorado State Department of Regulatory Agencies by calling 303-894-5957 or I have read and understand this notification. ______________ _________________________________________________ Date If this notification is signed by a personal representative on behalf of the patient, complete the following: Personal Representative’s Name: ____________________________________________ Relationship to Patient: ____________________________________________________

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