Please bring your ID and Medical/Dental Insurance cards to all appointments

Subscriber’s Name

Dental Insurance Group No. ID No.

Relationship to patientRelationship to patient

Attorney: Date of Injury:

Auto Accident: Yes or No

On The Job Injury: Yes or No

Law Firm:

Phone: ( )

Case Worker Name: Phone: ( )

Claim No.

WORKER’S COMPENSATION COMPANY / MVA:

Insured’s Date of Birth:

PATIENT INFORMATION

PERSON RESPONSIBLE FOR PAYMENT/ PARENT IF MINOR

Name

Home Address

Mailing Address (if different) Email:

Date of Birth

Employer’s Name

Referring Doctor

General Dentist

Social Security No.

Orthodontist

Sex M F Marital Status M S D W O Home Phone ( )

Last First M.I.

Street City State Zip

Name

Date of Birth

Home Phone ( )

Relationship to patient

Address (if different)

Soc. Sec. No.

EmployerStreet

Last First M.I.

City State Zip

EMERGENCY CONTACT (OTHER THAN PATIENT)

Last First M.I.Name

Address

Relationship Phone No. ( )

Work Phone. ( )Street City State Zip

MEDICAL INSURANCE (NEED COPY OF CARD)

DENTAL INSURANCE (NEED COPY OF CARD)

Primary Insurance Group No. ID No.

Relationship to patient

Group No. ID No.

Employer

Employer

Relationship to patient

Subscriber’s Name

Subscriber’s SS# D.O.B.

Subscriber’s SS# D.O.B.

Subscriber’s SS# D.O.B.

Secondary Insurance

Subscriber’s Name

INJURY INFORMATION

I hereby authorize my physician to release any medical information necessary to process claims with any insurance companies. I also assign my physician all payments to which I am entitled for medical and surgical expenses related to the services reported herewith. I understand that I am financially responsible for all charges whether covered by insurance or not. I also understand that balances outstanding for more than 90 days will be subject to a processing fee. o Privacy Notice.I approve transfer of Medical and Dental records by email to my treating Dentist and Physicians.

Pat. Reg 45 11/08

X

X

X

Phone ( )

RELATIONSHIP TO PATIENT

RELATIONSHIP TO PATIENT

RELATIONSHIP TO PATIENT

Primary Care Doctor

Work Phone ( )

Company Name:

Phone ( )

Phone ( )

Phone ( )

Phone ( )

SIGNATURE

SIGNATURE

SIGNATURE

o UPDATE

o UPDATE

o UPDATE

DATE

DATE

DATE

Cell Phone ( )

PATIENT REGISTRATION

Permission for Verbal Communications

Head and Neck Surgical Associates _________________________________________________________________________________________________ (Print name of patient) (Date Of Birth) _________________________________________________________________________________________________ (Street address) (City, state, zip code) _________________________________________________________________________________________________ (Phone number)

I permit Head and Neck Surgical Associates, their physicians, nurses, and other personnel to discuss health information, in person or by telephone, with the following family members or friends involved in my medical care: (List family members/friends and state the person’s relationship to the patient).

(Name) (Phone Number) (Relationship)

1. ___________________________________________________________________________ 2. ____________________________________________________________________________________ 3. ____________________________________________________________________________________ 4. ____________________________________________________________________________________ 5. ____________________________________________________________________________________ Release of information under this document is limited to verbal discussions with my Health Care Providers. This document does not permit release of any written health information to the individuals named above. This authorization is limited to the following time frame from ______________ (date) to __________ (date). If no dates are indicated, this form will remain in effect for an unlimited amount of time. If, at any time, I do not want verbal discussions to be permitted between my Health Care Providers and any of the individuals named above, I must notify my Health Care Provider by contacting the Medical Records Department at 503-553-3650 Patient’s Signature: ________________________________________________ Date: ________________ If a representative on behalf of the patient signs this release, complete the following: Representative’s Name: __________________________________________________________________ Relationship to Patient: ___________________________________________________________________ Head and Neck Surgical Associates 1849 NW Kearney Suite 300 Portland, Oregon 97209 P. 503-553-3650 F. 503-224-9081 HNSA 93PVC

HealthHistoryForm

Patient’sName______________________________________ DateofBirth_____/_________/___________

Gender:Male/Female Height:_________ Weight:__________

Page1of2

Yourmedicalhistoryisimportanttothetreatmentyouwillreceive.Therefore,itisimportantthatyourespondtoeachquestionhonestlyandcompletely.Pleasecircleyourresponses.

Pleasedescribeyourcurrenthealth: Excellent Good Fair PoorPleasedescribethesymptomsyouarecurrentlyhavingtoday:______________________________________________________________

Havetherebeenanychangesinyourgeneralhealthinthepastyear? Yes NoIfyes,pleasedescribe:______________________________________________________________________________________________

Areyounowunderaphysician’scareforaparticularproblematthistime? Yes No

Ifyes,why?___________________________________________ Dateoflastphysicalexam____/______/_________

Haveyoueverbeenhospitalizedorhadaseriousillness? Yes No

Ifyes,why?_______________________________________________________________________________________________________

FAMILYMEDICALHISTORYDoyouhaveafamilyhistoryofanyofthefollowing?Ifyes,indicatetherelationship.Diabetes?YesNoRelationship______________ Cancer?YesNoRelationship_____________

Heartdisease? YesNoRelationship______________ Bleedingproblems?YesNoRelationship_____________

Tumors?YesNoRelationship______________ Lungdisease? YesNoRelationship____________

PATIENTMEDICALHISTORYDoyouhaveorhaveyoueverhad:

Congenitalheartdisease,cardiovasculardisease(heartattack,heartmurmur,coronaryarterydisease,chestpain,high/lowbloodpressure,stroke,irregularheartbeat,heartsurgery,pacemaker)?

Yes No Lungdisease(asthma,emphysema,COPD,chroniccough,bronchitis,pneumonia,tuberculosis,shortnessofbreath,chestpain,severecoughing)?

Glaucoma?

Yes

Yes

No

No

Implantsplacedanywhereinthebody(heartvalve,pacemaker,hip,knee)?

Yes No Bleedingdisorder,anemia,bleedingtendency,bloodtransfusion?Doyoubruiseeasily?

Yes No

Kidneydiseaseorkidneyfailure,requiringdialysis? Yes No Liverdisease(jaundice,hepatitisA,B,orC)? Yes No

Thyroiddisease? Yes No Diabetes? Yes No

Stomachulcersorcolitis? Yes No Arthritis? Yes No

Clicking,popping,orpainwithinthejawjointand/ordifficultyopeningmouth?

Yes No Significantweightlossorgain?

Seizures,convulsions,epilepsy,faintingordizziness?

Yes

Yes

No

No

Frequentorrecurringmouthsores? Yes No Sinusornasalproblems? Yes No

Radiationtotheheadorneckforcancertreatment? Yes No Osteoporosisorosteopenia? Yes No

Anydisease,chemotherapyortransplantoperation?Cancer? Yes NoIfso,where?_______________________________________,andwhenwasthedateofyourlasttreatment?_______________________

Doyouhaveanyotherdisease,conditionorproblemnotlistedabovethatyouthinkthedoctorshouldknowabout? YesNo

Ifyes,pleaseexplain:____________________________________________________________________________

HealthHistoryForm

Patient’sName______________________________________ DateofBirth_____/_________/___________

Page2of2

FEMALEPATIENTSAreyoupregnant,oristhereanychanceyoumightbepregnant?YesNo

ALLERGIESAreyouallergictoorhaveyouhadanadversereactionto:Latex? YesNo Codeineorotherpainkillers? YesNo

Foodproducts? YesNo Aspirin,Motrin,Aleve,oribuprofen? YesNo

Sedatives,barbiturates? YesNo Penicillinorotherantibiotics? YesNo

Haveyouoranimmediatefamilymemberhadanyproblemassociatedwithlocalanesthesia,generalanesthesia,and/orintravenous

sedation? Yes No Ifyes,whichanesthetic?______________Relationship?_________________

Otherdrugallergiesnotlistedabove:________________________________________________________________________

SOCIALHISTORYHaveyoueversmokedorchewedtobacco?YesNo Ifyes,forhowlong?______________________________________

Haveyoueversoughtprofessionalcareorbeenhospitalizedfor: Doyouuse:Drugabuse? YesNo Alcohol? YesNo Howoften?_____________Emotionaldisorders?YesNoAlcoholism? YesNo

Marijuana? YesNo Howoften?_____________Recreationaldrugs?YesNo Howoften?_____________

Areyoucapableofmakingyourowninformedmedical/dentaldecisionstoday?YesNo

DENTALHISTORYHaveyouhadanyadverseeffectsfromdentaltreatment?YesNoIfYes,pleaseexplain?___________________________

Doyouwishtotalktothedoctorprivatelyaboutanything?YesNo

Iunderstandtheimportanceofatruthfulandcompletehealthhistorytoassistmydoctorinprovidingthebestcarepossible.Tothebestofmyknowledge,theaboveinformationiscompleteandcorrect.

__________________________________________Date

__________________________________________

______________________Signatureofpatient,parent,guardian

__________________________________________________________Printednameofpatient,parent,guardian/Relationship

HH69 07/17

Doctor’sSignature

MEDICATIONSAreyouusinganyofthefollowing:

Antibiotics? Yes No AspirinordrugssuchasMotrin,Aleve,Ibuprofen? Yes No

Anticoagulants(bloodthinners)? Yes No Insulinororalanti-diabeticdrugs? Yes No

Heartdrugs? Yes No Highbloodpressuremedications? Yes No

Steroids(cortisone,prednisone,etc.)?antianxietyagents,sedative-hypnoticsandantidepressants

Prescriptionpainmedication?

Yes

Yes

No

No

Bisphosphonates,antiangeogenicand/orantiresorptivemedicationsforosteoporosis,multiplemyelomaorothercancers?Ifyes,listdrugsusedandtimeofuse.____________________________________________________________________________________________________

Yes No

Pleaselistanyothermedicationsyouhavetakenorarecurrentlytakingnotlistedaboveincludingprescriptionmedications,dietdrugs,overthecountermedications,herbalorholisticremedies,vitaminsorminerals:_______________________________________________

NAME: ________________

DOB: ________________

PAST SURGICAL HISTORY:

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

MEDICATION LIST:

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

ALLERGIES/REACTION:

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

Our practice is committed to providing the best treatment for our patients. Patients are responsible for all charges resulting from treatment provided by their physician. As a service to you, we will bill most insurance carriers directly. However, primary responsibility for the account is yours. Please confirm your insurance benefits and coverage with your insurance company. While we do this for you as a courtesy, there have been (rare) occasions we were misquoted by your insurance company during the verification process. Providing correct insurance billing information is the responsibility of the patient. If your insurance changes, please present your insurance card at your next visit. All patients must complete our patient registration form before seeing the doctor.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDSComplete Lines 1-8. (Numbers 9-11 are optional)

1. Patient's Name (First) (Middle) (Last)

2. Date of Birth Patient Phone

Permission is hereby granted for release of information3. FROM: Name: Address:

4. TO: Name: Address:

Phone: Fax:

Authorization forrelease

OFFICE USE ONLY

Dr.'s initials

5. The purpose of the release is Diagnostic Evaluation Follow-up Care Legal Reimbursement Other6. The following information may be released: Clinic Notes (RE: ) Laboratory Reports X-ray Films All Records Immunization Records Medication Records X-ray Reports Other

7. (Signature of Patient or Representative) Relationship (if signed by representative) Date Signed

8. I do / do not specifically consent to transmission of my medical records via a facsimile (fax) machine.

9. I recognize that the information disclosed may contain drug/alcohol information that is protected by federal and state law. I specifically consent to disclosure of such information.

(Signature) (Date)

(Signature) (Date)

10. I recognize that the information disclosed may contain mental health information that is protected by federal and state law. I specifically consent to disclosure of such information.

(Signature) (Date)

11. I recognize that the information disclosed may contain information regarding sexually transmitted diseases or HIV/AIDS testing information. I specifically consent to disclosure of such information.

This consent will expire on (maximum 3 years)This consent is subject to revocation at any time except to the extent that action has been taken in reliance upon thisconsent before notice of revocation was received. (Back records for a maximum of two years only).

HNSA84ARMR 03/10

(Signature) (Date)

Medical Records CoordinatorPhone: 503.553.3650

Fax: 503.224.90811849 NW Kearney St., Suite 300

Portland, OR 97209-1412