Patient Registration Forms | First Coast OMS

3 Convenient Locations

LAKE CITY

(386)243-8343

1779 SW Barnett Way #103

Lake City, FL 32025

AMELIA ISLAND

(904)491-0111

960115 Gateway Boulevard #1
Amelia Island, FL 32034

JACKSONVILLE

(904)565-1505

7711 Baymeadows Rd E. #7
Jacksonville, FL 32256

- NEW LOCATION -

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PATIENT REGISTRATION FORM

If you have an upcoming appointment with our office, please fill out the registration form ahead of your appointment.

Patient's Information

First Name

Date of Birth (MM/DD/YY)

Middle Initial

Last Name

Gender

Address

City

State

Zip Code

Contact Information

Cell Phone

Home Phone/Second Phone

Emergency Contact

Employer Information

Employer Name

Occupation

Insurance Information

Insurance Company

Policy #

Group ID

Insurance Policy Holder Information (if it is not you)

Full Name

Relationship of Patient to Insured

Date of Birth (MM/DD/YY)

Social Security #

Gender

Full Address

Phone Number

Employer Company

Health History

YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

My last physical exam was on:

Physician’s Name and Phone

Are you in good health?

Yes

Have you had any serious illnesses, hospitalizations or surgeries in the past five years?

Yes

Do you drink alcohol?

Yes

Do you use marijuana or other “street” drugs?

Yes

Do you smoke or use other tobacco products?

Yes

Are you taking any blood thinners? (Aspirin, Plavix, Coumadin, Xarelto)

Yes

Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers? (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Xgeva, Prolia)

Yes

Please list all medications (prescribed or over-the-counter)

Women ONLY:

Pregnant

Nursing

Are you taking birth control pills?

Please check any diseases or problems you have.

Rheumatic fever or rheumatic heart disease

Liver disease (hepatitis, jaundice)

Bleeding disorder, anemia, blood transfusion, do you bleed easily?

Psychiatric care

Seizures, convulsions, epilepsy, fainting, dizziness

Cardiovascular disease (heart trouble, heart attack, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations, heart surgery, pacemaker)

Lung disease (asthma, emphysema, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)

Kidney disease

Diabetes

Hyperthyroid/hypothyroid

Arthritis or painful, swollen joints

Stomach ulcers, colitis, reflux disease

Glaucoma

Frequent or recurring mouth sores

Bleeding disorder, anemia, blood transfusion, do you bleed easily?

Implants placed anywhere in your body (heart valve, hip, knee)

History of cancer

Radiation (X-Ray) treatment for cancer

Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth

Sinus or nasal trouble

Any disease, drugs or transplant operation that has depressed your immune system

Recurrent infections of any kind

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

Yes

Allergies:

Are you allergic to any medications? (If yes, please mark below)

Yes

Penicillin

Sulfa drugs

Local anesthetic

Latex or rubber

Other:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I consent to use Electronic Records and SignaturesRead Electronic Record and Signature Disclosure

Thanks for submitting, a team member will be in contact!

FIRST COAST ORAL & MAXILLOFACIAL SURGERY

Jacksonville Oral Surgeons, Dr. Andrew L. Skigen, Dr. Anthony Massaro, and Dr. Tyler Woodling manage a wide variety of problems relating to the mouth, teeth and facial regions. For more information about the oral and maxillofacial surgery services we provide, or to schedule a consultation, click the button below! You can also call our Jacksonville, FL office to talk to a team member!

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Site Designed and Maintained by Bailey Bruce Creative

Jacksonville

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Office Hours

7711 Baymeadows Rd E. #7
Jacksonville, FL 32256

Fax: 904-565-1506

(904)565-1505

8 AM - 4 PM

8 AM - 12 PM

Lake City

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Office Hours

1779 SW Barnett Way, #103

Lake City, FL 32025

Fax: 904-565-1506

(386) 243-8343

8 AM - 4 PM

8 AM - 12 PM

Amelia Island

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Office Hours

960115 Gateway Boulevard #1

Amelia Island, FL 32034

Fax: 904-491-0222

(904)491-0111

9 AM - 3 PM

9 AM - 3 PM
9 AM - 3 PM
9 AM - 3 PM

9 AM - 3 PM

Proudly serving Jacksonville, Lake City, Amelia Island, and the surrounding areas:

Jacksonville FL • Amelia Island FL • St. Johns, FL • Ponte Vedra FL • Nocatee FL • Lake City FL • O'Neil FL • Yulee FL • Fernandina Beach FL• Callahan FL • Orange Park FL • Palm Coast FL • St. Augustine FL • Gainesville FL • Kingsland GA • Brunswick GA • Wellborn FL • White Springs FL • Lulu FL • Alachua FL • Macclenny FL • Live Oak FL

FIRST COAST OMS

PATIENT REGISTRATION FORM

Patient's Information

Contact Information

Employer Information

Insurance Information

Insurance Policy Holder Information (if it is not you)

Health History

YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

Women ONLY:

Please check any diseases or problems you have.

Allergies:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

FIRST COAST ORAL & MAXILLOFACIAL SURGERY

© 2020 First Coast Oral & Maxillofacial Surgery

Site Designed and Maintained by Bailey Bruce Creative

Monday:

7711 Baymeadows Rd E. #7
Jacksonville, FL 32256

8 AM - 4 PM

Monday:

8 AM - 4 PM

Monday:

960115 Gateway Boulevard #1

Amelia Island, FL 32034

9 AM - 3 PM

Proudly serving Jacksonville, Lake City, Amelia Island, and the surrounding areas:

© 2020 by First Coast OMS. Proudly created by Bailey Bruce Creative

FIRST COAST OMS

PATIENT REGISTRATION FORM

Patient's Information

Contact Information

Employer Information

Insurance Information

Insurance Policy Holder Information (if it is not you)

Health History

YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

Women ONLY:

Please check any diseases or problems you have.

Allergies:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

FIRST COAST ORAL & MAXILLOFACIAL SURGERY

​

© 2020 First Coast Oral & Maxillofacial Surgery

Site Designed and Maintained by Bailey Bruce Creative

Monday:

7711 Baymeadows Rd E. #7 Jacksonville, FL 32256

8 AM - 4 PM

Monday:

8 AM - 4 PM

Monday:

960115 Gateway Boulevard #1

Amelia Island, FL 32034

9 AM - 3 PM

Proudly serving Jacksonville, Lake City, Amelia Island, and the surrounding areas:

​

© 2020 by First Coast OMS. Proudly created by Bailey Bruce Creative

7711 Baymeadows Rd E. #7
Jacksonville, FL 32256