Monday to Friday8:30AM - 5PM
Address311 Commonwealth Ave, Boston, MA 02115, USA
Phone617-267-4777
 
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Patient intake form
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Patient intake form

Patient intake form

    Part 1/4: Patient information


     


     


     


     
    In case of emergency

    Part 2/4: Insurance information

    Do you have dental insurance?


     


     


     


     

    Part 3/4: Health history

    To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have and medication that you may be taking could have an important interrelationship with the care that you will be receiving.

    Please answer the following questions:

    1. Are you in good health?

    2. Have there been any changes in your general health in the past year?

    3. Are you under the care of a physician?

    4. Have you had any illnesses, operation or have been hospitalizes in the past 5 years?

    5. Are you taking any medication(s) including non-prescription, homeopathic, natural remedies or vitamins?

    Pharmacy

     

    6. Do you or have you ever had any of the following diseases or problems?

    a. Heart trouble, heart attack, angina, high blood pressure, stroke, arteriosclerosis or any other heart condition

    b. Rheumatic heart disease

    c. Damaged heart valves, artificial valves or heart murmur

    d. Chest pain upon exertion

    e. Shortness of breath after mild exercise

    f. Do your ankles swell

    g. Allergies or hay fever

    h. Sinus trouble

    i. Asthma

    j. Fainting spells or seizures

    k. Diabetes

    l. Hepatitis, jaundice or liver disease

    m. Frequent or recurring mouth sours

    n. Thyroid problems

    o. Respiratory problems, emphysema, bronchitis, etc.

    p. Arthritis or painful, swollen joints including jaw joint (TMJ)

    q. Stomach ulcer or hyperacidity

    r. Kidney trouble

    s. Tuberculosis

    t. Persistent swollen neck glands

    u. Epilepsy or neurological disorder

    v. Any disease, drug or transplant operation that has depressed your immune system

    w. Have you ever had treatment for a tumor or growth

    x. Cancer

    y. Have you ever had abnormal bleeding

    z. Have you ever required a blood transfusion

     

    7. Are you allergic to or have you had a reaction to:

    a. Local anesthetics

    b. Penicillin or antibiotics

    c. Sulfa drugs

    d. Aspirin

    e. Barbiturates or sleeping pills

    f. Codeine or other narcotics

    g. Iodine

    h. Other

     

    8. Do you have any other condition or disease you think the doctor should know about?

    9. Do you smoke?

    10. Do you use recreational drugs?

    11. Are you wearing contact lenses?

    12. Are you wearing removable dental appliances?

    13. Do you wish to talk to the doctor privately about anything?


     
    If you are a woman

    14. Are you pregnant or trying to become pregnant?*

    15. Do you have problems associated with your menstrual period?*

    16. Are you nursing?*

    17. Are you taking any form of oral contraceptive?*

    Part 4/4: Policies and consent

    Cellphone use policy
    I provide consent to Back Bay Oral and Maxillofacial Surgery dental practice to use my cellphone number to contact me regarding treatment, insurance and my account with the method chosen below. I understand that I can withdraw my consent at any time.
    I consent

    Choose the best way to contact you*

     
    Notice of privacy policy
    I acknowledge that I have received a copy of Back Bay Oral & Maxillofacial Surgery's Notice of Privacy Policy. I have been given the opportunity to ask any questions regarding this notice.
    I confirm

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

    We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager in advance 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, but please complete the identifying information on this form. 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.

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    Whether you are a patient or a referring dentist, every time you do business with Back Bay Oral and Maxillofacial Surgery, you are guaranteed a unique and pleasant experience.

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    Working Hours
    Monday
    8AM - 5:30PM
    Tuesday
    8AM - 5:30PM
    Wednesday
    8AM - 5:30PM
    Thursday
    8AM - 5:30PM
    Friday
    8AM - 5:30PM
    Saturday - Sunday
    Closed
    Contact us
    Phone : 617-267-4777
    Fax : 617-267-1277
    Write to us

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