Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name

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Prudence Harmon
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1 Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address (if different) Date of Birth Sex M F Marital Status M S D W O Home Cell Employer s Name Work Referring Doctor General Dentist Primary Care Doctor Orthodontist PERSON RESPONSIBLE FOR PAYMENT/ PARENT IF MINOR Name Last First M.I. Relationship to patient Soc. Sec.. Date of Birth Address (if different) Street City State Zip Home Employer EMERGENCY CONTACT (OTHER THAN PATIENT) Name Relationship Phone. ( ) Last First M.I. Address Work Phone. ( ) Street City State Zip MEDICAL INSURANCE (NEED COPY OF CARD) Primary Insurance Group. ID. Subscriber s Name Relationship to patient Employer Subscriber s SS# D.O.B. Secondary Insurance Group. Subscriber s Name Relationship to patient Subscriber s SS# D.O.B. DENTAL INSURANCE (NEED COPY OF CARD) ID. Employer Dental Insurance Group. ID. Subscriber s Name Subscriber s SS# INJURY INFORMATION Attorney: Law Firm: Phone: ( ) WORKER S COMPENSATION COMPANY / MVA: Relationship to patient D.O.B. Date of Injury: Case Worker Name: Phone: ( ) Company Name: Auto Accident: or On The Job Injury: or Claim. Insured s Date of Birth: 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 tice. I approve transfer of Medical and Dental records by to my treating Dentist and Physicians. X X X SIGNATURE SIGNATURE SIGNATURE o UPDATE o UPDATE o UPDATE RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT DATE DATE DATE Pat. Reg 45 11/08

2 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) 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 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 P F HNSA 93PVC

3 Health History Form Patient s Name Date of Birth / / Gender: Male / Female Height: Weight: Your medical history is important to the treatment you will receive. Therefore, it is important that you respond to each question honestly and completely. Please circle your responses. Please describe your current health: Excellent Good Fair Poor Please describe the symptoms you are currently having today: Have there been any changes in your general health in the past year? If yes, please describe: Are you now under a physician s care for a particular problem at this time? If yes, why? Date of last physical exam / / Have you ever been hospitalized or had a serious illness? If yes, why? PATIENT MEDICAL HISTORY Do you have or have you ever had: Congenital heart disease, cardiovascular disease (heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)? Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)? Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)? Glaucoma? Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily? Kidney disease or kidney failure, requiring dialysis? Liver disease (jaundice, hepatitis A, B, or C)? Thyroid disease? Diabetes? Stomach ulcers or colitis? Arthritis? Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth? Significant weight loss or gain? Seizures, convulsions, epilepsy, fainting or dizziness? Frequent or recurring mouth sores? Sinus or nasal problems? Radiation to the head or neck for cancer treatment? Osteoporosis or osteopenia? Any disease, chemotherapy or transplant operation? Cancer? If so, where?, and when was the date of your last treatment? Do you have any other disease, condition or problem not listed above that you think the doctor should know about? If yes, please explain: FAMILY MEDICAL HISTORY Do you have a family history of any of the following? If yes, indicate the relationship. Diabetes? Relationship Cancer? Relationship Heart disease? Relationship Bleeding problems? Relationship Tumors? Relationship Lung disease? Relationship Page 1 of 2

4 Patient s Name Health History Form FEMALE PATIENTS Are you pregnant, or is there any chance you might be pregnant? MEDICATIONS Are you using any of the following: Date of Birth / / Antibiotics? Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Anticoagulants (blood thinners)? Insulin or oral anti-diabetic drugs? Heart drugs? High blood pressure medications? Steroids (cortisone, prednisone, etc.)? antianxiety agents, sedative-hypnotics and antidepressants Prescription pain medication? ALLERGIES Are you allergic to or have you had an adverse reaction to: Latex? Codeine or other pain killers? Food products? Aspirin, Motrin, Aleve, or ibuprofen? Sedatives, barbiturates? Penicillin or other antibiotics? Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation? If yes, which anesthetic? Relationship? Other drug allergies not listed above: SOCIAL HISTORY Have you ever smoked or chewed tobacco? If yes, for how long? Have you ever sought professional care or been hospitalized for: Do you use: Drug abuse? Alcohol? How often? Emotional disorders? Marijuana? How often? Alcoholism? Recreational drugs? How often? Are you capable of making your own informed medical/dental decisions today? DENTAL HISTORY Have you had any adverse effects from dental treatment? If, please explain? Do you wish to talk to the doctor privately about anything? Bisphosphonates, antiangeogenic and/or antiresorptive medications for osteoporosis, multiple myeloma or other cancers? If yes, list drugs used and time of use. Please list any other medications you have taken or are currently taking not listed above including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals: I understand the importance of a truthful and complete health history to assist my doctor in providing the best care possible. To the best of my knowledge, the above information is complete and correct. Signature of patient, parent, guardian Date Printed name of patient, parent, guardian/relationship Doctor s Signature HH69 07/17 Page 2 of 2

5 NAME: DOB: PAST SURGICAL HISTORY: MEDICATION LIST: ALLERGIES/REACTION:

9 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Complete 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 information 3. FROM: Name: Address: 4. TO: Name: Address: Phone: Fax: Authorization for release OFFICE USE ONLY Dr.'s initials 5. The purpose of the release is Diagnostic Evaluation Follow-up Care Legal Reimbursement Other 6. The following information may be released: Clinic tes (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. (Signature) (Date) 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) 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. (Signature) (Date) 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 this consent before notice of revocation was received. (Back records for a maximum of two years only). HNSA84ARMR 03/10 Medical Records Coordinator Phone: Fax: NW Kearney St., Suite 300 Portland, OR

Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female

Patient Registration Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Email: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female Marital Status: Single Married Widowed