Cy-Fair Oral Surgery Intake Form

Name *

First Name Last Name

Date of Birth *

Month Day Year

Address *

Street Address

Street Address Line 2

City State

Zip Code

Primary Phone *

Other Phone

E-mail

Is the patient a full-time student? *

Yes No

If yes, Name of School

Employer *

Employer Phone Number

Who may we thank for referring you?

Have we treated any other family member? *

Yes No

Reason for Visit *

Last Dental Exam

Month Day Year

Name of Dentist

Dentist's Phone Number

Name of Medical Doctor

Phone Number

Please list allergies to drugs:

Do you have any of the following conditions? If yes, please check. If no, please select "I do not have any medical conditions" *

Describe any current medical treatments, including drugs taken even if might also be checked above:

I understand that, under Health Insurance Portability Act of 1998 (HIPPA) I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

- Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in my treatment directly and indirectly

- Obtain payment from third party payers

- Conduct normal health care operations such as quality assessment and physician certification

I have been informed by you of your Notice of Privacy Practices prior to signing this consent; I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand I may request in writing that you restrict how my private information is used and disclosed to carry out treatments, payments or health care operations. I also understand that you are not required to agree to my requested restrictions, but you do agree then that you are bound by such restrictions, but if you do not agree then you are not bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on the consent.