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

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Contact Information

Employer Information

Insurance Information

Insurance Policy Holder Information (if it is not you)

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Health History

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

Are you in good health?
Have you had any serious illnesses, hospitalizations or surgeries in the past five years?
Do you drink alcohol?
Do you use marijuana or other “street” drugs?
Do you smoke or use other tobacco products?
Are you taking any blood thinners? (Aspirin, Plavix, Coumadin, Xarelto)
Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers? (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Xgeva, Prolia)

Women ONLY:

Please check any diseases or problems you have.

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

Allergies:

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

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 

 

Jacksonville Oral Surgeons, Dr. Andrew L. Skigen and Dr. Anthony Massaro, 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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© 2020 First Coast Oral & Maxillofacial Surgery

Site Designed and Maintained  by Bailey Bruce Creative

Jacksonville

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Office Hours

7711 Baymeadows Rd E. #7
Jacksonville, FL 32256

Fax: 904-565-1506

(904)565-1505

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

8 AM - 12 PM

Lake City

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Office Hours

1779 SW Barnett Way, #103

Lake City, FL 32025

Fax: 904-565-1506

(386) 243-8343

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

8 AM - 12 PM

Amelia Island 

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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

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