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Follow up news after surgery

Dr. Roland Hernandez
General Patient Information
Emergency Contact
Responsible For Account. if self, skip to next section
Insurance Information

Martial Status:


Medical History

*Health problems or medication can have an important interrelationship with the care you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

ALLERGIES: Are you allergic or have you had a bad reaction to any of the following?:

Local Anesthetic (Numbing Med.)
Sulfa Drugs
Sodium Pentothal, Valium or Other Tranquilizers
Codeine or Other Narcotics
Other Antibiotics

Please list all known allergies and reactions to medications:

I have no known allergies.

MEDICATIONS: Are you taking or have you ever taken any of the following?:

Blood Thinners (Coumadin, Plavix, Asprin, Vitamin E, Ginko Biloba)
Diet Pills
Any bone density medication/Bisphosphonates (Aredia,Zometa,Fossamax,Actonel, Evista,Prolia, Forteo)
Tranquilizers, Sleepig Pills, Anti-Depressants and/or Narcotics on a Regular Basis
If so, please list:
Please list all current medications, including non-perscription, homeopathic, and natural remedies:
Currently taking no medications

Reason for today's office visit:
Are you in good health?YesNo
Has there been any change in your general health in the past year?YesNo
Are you now under the care of a physician?YesNo
- If yes, for what conditions?
Have you had any serious illnesses, operations or hospitializations?YesNo
- If yes, please explain:
Do you have unhealed/recurent injuries or inflamed areas, growths or sore spots in or around your mouth?YesNo
- If yes, please explain:
Do you have a prosthetic joint/implant?YesNo
- If yes, please describe where:
Have you had a heart valve replacement or vascular graft?YesNo
Are you on a diet?YesNo
Do you wear contact lenses?YesNo
Do you wear a removable dental appliance?YesNo
Have you had or do you currently have:
Rheumatic Fever
Difficult Breathing
Thyroid Trouble
Delay in Healing
Damaged Heart Valve/Mitral Valve Prolapse
Other Lung Trouble
Stomach Ulcers
Low Blood Sugar
Kidney Trouble
Heart Murmur
On Dialysis
Eye Disease/Glaucoma
High Blood Preassure
Blood Transfusion
Swollen Ankles, Arthiritis Or Joint Disease
Tumor or Growth
Low Blood Pressure
Anemia/Other Blood Disorder
Radiation Thereapy or Chemotherapy
Chest Pain/Angina
Bruise Easily
Heart Attack(s)
Bleeding Tendency
Chronic Fatigue or Night Sweats
Irregular Heart Beat
Hepatitis, Jaundice or Liver Disease
Contagious Diseases
Cardiace Pacemaker
Sexually Trasmitted Diseases
Mental Health Problems
Heart Surgery
Infections Mononucleosis
Disease/Drug/Transplant that has Suppressed Immune System
Pain or Clicking of Jaws When Eating
Bronchitis or Chronic Cough
Gallbladder Trouble
Fainting Spells
Immune System Trouble/Problems From Medication, Surgery, Etc.
Malignant Hyperthermia
Hay Fever/Sinus Problems
Smoke or Chew Tobacco
Snoring/Sleep Apnea
History of Drug Abuse
History of Alcohol Abuse
Notes for any of the above checked:

Is there a family history of:

Heart Disease
Anesthetic Problems
Is there any condition concerning your health that the doctor should be told about?YesNo
- If yes, please describe:
Do you wish to speak to the doctor privately about anything about?YesNo


if No, skip to next section.

Is this visit related to an accident?YesNo
If Yes:
Work Related

Date of injury:

Insurance Company handling this claim

Claim Number

Name of Attorney or Adjustor:

Phone #:

Are you pregnant or is there any chance you might be pregnant?YesNo

-If yes, expecting delivery date:

Are you nursing?YesNo
Are you taking birth control pills?YesNo

Please Note: Antibiotics (such as Penicillin) may alter the effectiveness of birth control pill. Consult your physician or gynecologist for assistance regarding additional methods of birth control.

I certify that I have read and 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 the staff, responsible for any errors or omissions that I have made in the completion of this form.

(Parent or Legal Guardian If Minor)
Fees & Payments

Arrangements can be made with our office manager depending upon special circumstances. An estimate 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 fill out the proper forms.

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 percentage 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. You will be responsible for all collection costs, attorneys fees and court costs.

(Parent or Legal Guardian If Minor)

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

(Parent or Legal Guardian If Minor)

I authorize my surgeon and his designated staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treament planning. Futhermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

(Parent or Legal Guardian If Minor)

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

(Parent or Legal Guardian If Minor)
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