Welcome to Fujioka Center for Dental Sleep Medicine!

New Sleep Patient Registration Form

Please fill out our New Sleep Patient Form before your first visit.

* required field (please fill out ALL required fields)

ABOUT YOU

Name:*
First Middle Last
What you prefer to be called:
Gender:*
- Male
- Female
Birthdate:*
Age:*
SSN:*
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone #:
Work Phone #:
Cell phone #:
Email address:*
Referred by:
Employer:
How long?
Occupation:
Employer address:
Street Address City State ZIP Code
Status:
- Minor
- Single
- Married
- Divorced
- Seperated
- Widowed
Spouse's name:
INSURANCE INFO
Primary Medical Insurance / Medicare Insurance
Company name:
Company phone#:
Company address:
Street Address City State ZIP Code
Insured's ID:
Group # (Plan, Local or Policy #):
Insured's name:
Insured's employer:
Relation:
Birthdate:
Secondary Medical Insurance / Supplemental Medicare Insurance
Company name:
Company phone#:
Company address:
Street Address City State ZIP Code
Insured's ID:
Group # (Plan, Local or Policy #):
Insured's name:
Insured's employer:
Relation:
Birthdate:
ACCOUNT INFO
Person ultimately responsible for the account
Name:*
First Last
Relation:*
Billing address:*
Street Address City State ZIP Code
SSN:*
Drivers license #:
Work phone #:
Initials:*
I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).
IN THE EVENT OF AN EMERGENCY
Whom should we contact?*
Relation:*
Primary phone #:*
Alternate phone #:
Who is your medical doctor?
Medical doctor's phone #:
DENTAL INFORMATION
Current dentist name:
Phone #:
Last dental exam:
Last dental x-rays:
SLEEP INFORMATION
Who is your medical doctor?
Phone #:
Doctor phone number.
Have you had a sleep study done?*
- Yes
- No
If yes, please list address of sleep study location:
Date of sleep study:
MM slash DD slash YYYY
Who was the ordering physician?
Do you currently use a CPAP or oral appliance?
If so, when did you receive it?
MEDICAL HISTORY
Are you under a physician's care now?*
- Yes
- No
If yes, please explain:
Have you ever been hospitalized or had a major operation?*
- Yes
- No
If yes, please explain:
Have you ever had a serious head or neck injury?*
- Yes
- No
If yes, please explain:
Are you taking any medications, pills or drugs?*
- Yes
- No
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?*
- Yes
- No
If yes, please explain:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
- Yes
- No
If yes, please explain:
Do you use tobacco?*
- Yes
- No
If yes, please explain:
Do you use controlled substances?*
- Yes
- No
If yes, please explain:
Do you use marijuana?*
- Yes
- No
If yes, please explain:
WOMEN:
Are you Pregnant/Trying to get pregnant?*
- Yes
- No
Taking Oral Contraceptives?*
- Yes
- No
Nursing?*
- Yes
- No
Do you take herbal supplements or other OTC products ex: fish oil or vitamins?*
- Yes
- No
If yes, please list:
Are you allergic to any of the following?*
- Aspirin
- Penicillin
- Codeine
- Local Anesthetics
- Acrylic
- Metal
- Latex
- Sulfa Drugs
- Other (please list)
- None of the above
If yes, please explain:
Are you allergic to anything not listed? Please specify.
Do you have, or have you had, any of the following?
AIDS/HIV Positive*
- Yes
- No
Alzheimer's Disease*
- Yes
- No
Anaphylaxis*
- Yes
- No
Anemia*
- Yes
- No
Angina*
- Yes
- No
Anxiety*
- Yes
- No
Arthritis / Gout*
- Yes
- No
Artificial Heart Valve*
- Yes
- No
Artificial Joint*
- Yes
- No
Asthma*
- Yes
- No
Blood Disease*
- Yes
- No
Blood Transfusion*
- Yes
- No
Breathing Problem*
- Yes
- No
Bruise Easily*
- Yes
- No
Cancer*
- Yes
- No
Chemotherapy*
- Yes
- No
Chest Pains*
- Yes
- No
Cold Sores / Fever Blisters*
- Yes
- No
Congenital Heart Disorder*
- Yes
- No
Cortisone Medicine*
- Yes
- No
Depression*
- Yes
- No
Diabetes*
- Yes
- No
Drug Addiction*
- Yes
- No
Emphysema*
- Yes
- No
Epilepsy or Seizures*
- Yes
- No
Excessive Bleeding*
- Yes
- No
Excessive Thirst*
- Yes
- No
Fainting Spells / Dizziness*
- Yes
- No
Frequent Cough*
- Yes
- No
Frequent Headaches*
- Yes
- No
Dementia*
- Yes
- No
Glaucoma*
- Yes
- No
Hay Fever*
- Yes
- No
Heart Attack / Failure*
- Yes
- No
Heart Murmur*
- Yes
- No
Heart Pacemaker*
- Yes
- No
Heart Trouble / Disease*
- Yes
- No
Hemophilia*
- Yes
- No
Hepetitis A*
- Yes
- No
Hepetitis B or C*
- Yes
- No
Herpes*
- Yes
- No
High Blood Pressure*
- Yes
- No
High Cholesterol*
- Yes
- No
Hives or Rash*
- Yes
- No
Hypoglycemia*
- Yes
- No
Irregular Heartbeat*
- Yes
- No
Kidney Problems*
- Yes
- No
Leukemia*
- Yes
- No
Liver Disease*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Lung Disease*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Osteoporosis*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Parathyroid Disease*
- Yes
- No
Parkinson's Disease*
- Yes
- No
Psychiatric Care*
- Yes
- No
Radiation Treatments*
- Yes
- No
Renal Dialysis*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Rheumatism*
- Yes
- No
Scarlet Fever*
- Yes
- No
Shingles*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Sinus Trouble*
- Yes
- No
Spina Bifida*
- Yes
- No
Stomach / Intestinal Disease*
- Yes
- No
Stroke*
- Yes
- No
Thyroid Disease*
- Yes
- No
Tonsillitis*
- Yes
- No
Tuberculosis*
- Yes
- No
Tumors or Growths*
- Yes
- No
Ulcers*
- Yes
- No
Venereal Disease*
- Yes
- No
Have you ever had any serious illness not listed above?
- Yes
- No
Comments:
Please check the required boxes:*
- Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
Untitled*
- I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
Untitled*
- I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Untitled*
- I understand that if I am not able to keep an appointment I am required to inform Fujioka Family Dentistry at least 24 hours in advance. If 24 hour notice is not given, I will be charged a $50 cancellation fee.
I acknowledge that I have reviewed the Statement of Privacy Practices
I have read the Statement of Privacy Practices*
Signature (Please Type Full Name):*
*
- Adult Patient
- Parent or Guardian
- Spouse
Date*
MM slash DD slash YYYY
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Welcome to Fujioka Center for Dental Sleep Medicine!

New Sleep Patient Registration Form

* required field (please fill out ALL required fields)

ABOUT YOU

INSURANCE INFO

Primary Medical Insurance / Medicare Insurance

Secondary Medical Insurance / Supplemental Medicare Insurance

ACCOUNT INFO

IN THE EVENT OF AN EMERGENCY

DENTAL INFORMATION

SLEEP INFORMATION

MEDICAL HISTORY

Do you have, or have you had, any of the following?

STATEMENT OF PRIVACY PRACTICES