Signature Oral Surgery – Book a Consultation
1. Patient Information Preferred Method of Contact
2. Reason for Consultation What are you coming in for?
Please briefly describe what you are experiencing or what your dentist referred you for
Were you referred by another dentist or physician?
3. Symptoms & Urgency Your answers here help our clinical team identify patients who may need to be seen the same day.
Are you currently experiencing any of the following?
If you are having difficulty breathing or swallowing, rapidly spreading swelling, or bleeding that will not stop, call 911 or go to the nearest emergency room now. Do not wait for a consultation appointment.
How would you rate your pain? (0 = none, 10 = worst)
Is the condition getting:
Is this consultation related to a recent injury or emergency?
4. Medical History Do you currently have, or have you ever had, any of the following?
Are you currently taking any medications?
Do you have any medication or other allergies?
Please list allergies and reactions
5. Important Surgical Considerations Have you previously had surgery or anesthesia?
Have you ever had a problem with anesthesia or sedation?
Do you take blood thinners or medications that affect bleeding?
Are you currently pregnant or could you be pregnant?
6. Dental Information Have you had recent dental X-rays or a CBCT scan?
If available, can your referring dentist send your X-rays / records before your consultation?
7. Insurance & Payment Do you have secondary dental / medical insurance?
Would you like our office to verify your benefits before your appointment?
8. Appointment Preferences Preferred appointment timeframe
9. Records & Communication Authorization
10. Final Question Is there anything else you would like our oral surgery team to know before your consultation?
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