• PLEASE READ THIS BEFORE BEGINNING THIS FORM: 

    The form is going to ask for your Prescriptions -

    a) Name of each Medication

    b) Dose & Frequency

    c) Purpose (Example: High Blood Pressure)

    d) Prescribing Physician (or self)

    e) Include any Supplements, Vitamins, & Over the Counter Medications

  • Date Completing:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex:*
  • Date of Birth: *
     / /
    2 digit month, 2 digit day, 4 digit year
  • Today for age calculation:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you already provided our office your address?

  • Legal Consent: Patients under 18 cannot give consent. Other patients due to mental or other circumstances may not be capable of giving consent. For scheduling surgeries it is important to identify who we need to communicate with to coordinate care. Please call our office if you have any questions.

  • Is the Patient Able to Provide Legal Consent?*
  • Legal Guardian/Medical Surrogate:*
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  • Marital Status:*
  • Primary Contact Method:*
  • Do you have an Email Address?*
  • Will someone be accompanying the patient to the appointment? *
  • Contact for Pre-Appointment Arrangements?*
  • Person to Contact if Not Patient:
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  • Job/School/Retired:*
  • Do you give permission to access the pharmacy medications list? Often we can, with permission, access a patient's medications. This does not work for Kaiser, and military.
  • Accommodations:*
  • Special Needs: Please check all that apply*
  • Is the patient able to transfer to a dental chair?
  • Patient Case Coordinator:
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  • Medical Surrogate - Guardian:
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  • Number for Dr. Alman to Call to Check on the Patient the Evening of Surgery or Procedure?*
  • Have you been a patient of Dr. Alman?*
  • Has anyone in your family been a patient of Dr. Alman?*
  • Who referred you to Dr. Alman?*
  • Dental Specialist(s):
  • Purpose for the Appointment*
  • Is Implant Treatment Planned?

  • CONSULTATION AND BIOPSY APPOINTMENT:

    Dr. Alman has over 40 years of experience in the diagnosis and treatment of oral lesions.

    Pre-Appointment:

    • The referring dentist or phyisican often will often send photos and a description as to their observations. Sometimes they call Dr. Alman ahead of the appointment to dicuss the case.
    • Please indicate below any details to help the office ready for your appointment. Include the location, discription, and how long the lesion has been present.
    • We do allow enough time for a consultation and biopsy even if Dr. Alman may decide not to perform the biopsy. This saves the patient to need a second  appointment.

    Consultation and Biopsy Appointment:

         Time: 30 minutes to 1 hour.

         Biopsy Fees:

    • Consultation Only: If a biopsy is not required or performed the consutation fee is $350-400.
    • Biopsies Fees: From $450-$1,500. The fee will depend on the location and the complexity of the excision.
    • Dr. Alman is not a Participating Provider for any insurances medical or dental insurance plans. The Fees are paid at the appointment and the staff will assist with insurance filing (except for Medicare) & the member will be reimbursed directly according to the out-of-network benefits and limitations.
    • Pathology Lab & Lab Fees: If a biopsy is performed, it will be sent to Johns Hopkins Oral Pathology Lab. The head pathologist, Dr. Robert Foss, is a long time personal friend of Dr. Alman's. He personally takes care to quickly inform Dr. Alman if any biopsy has a negative diagnosis. The lab does participate with all insurance plans including Medicare. Our office will send the medical insurance information with the lab sample. 

    Follow-up Appointment(s):

    • If biopsy is performed, a follow-up appointment will be made 10 days to 2 weeks later. This appointment is usually scheduled for 15 minutes.
    • At this appointment, Dr. Alman will go over the biopsy report and give a copy to the patient for their records. Future care and follow-up will be discussed.
    • There is no fee for this follow-up appointment.
  • Are you in good health?*
  • Have you seen a primary care physician for an annual comprehensive physical in the past 12 months?*
  • Do you see a medical doctor for ANY reason other than routine care?*

  • Your Physician's Contact Information may be needed to contact them for medical clearance or medical manaagment. If you see multiple specialists please gather their information as well for later at the end of this form add each Name, Specialty, Telephone Number, Email, and Fax Number. We don't need the address but, the City, and State is appreciated.

  • Has there been any changes to your general health in the last 2 years?*
  • Have you ever had a Major Operation?*
  • Have you had an Illness, Operation, or been Hospitalized in the past 5 years?*
  • Do you have an Upcoming (or planned) Procedure or Surgery?*
  • Productive Cough: Have you had a chest cold, cough, or flu symptoms producing phlegm (sputum) in the last 2 weeks?*
  • Allergy to ANY Antibiotics? (Examples: Penicillin, Sulfa, & Tetracycline).*
  • Allergy to NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Aspirin / Ibuprofen / Advil / Aleve / Motrin?*
  • NSAIDs: Aspirin / Ibuprofen / Advil / Aleve / Motrin
  • Acetaminophen (Tylenol) Allergy?*
  • Acetaminophen (Tylenol)*
  • Allergy to Any Narcotics?*
  • Narcotics
  • Allergy to Sleeping Pills, Sedatives (Examples: Lunesta, Sonata, Ambien, Halcion), or Anti-Anxiety Medications (Examples: Xanax, Valium, Ativan, or Libram)?*
  • Allergy to Local Anesthetic?*
  • "Racing Heart" due to Epinephrine / Adrenaline Used in Local Anesthetics?*
  • Other ALLERGIES: Please Check ALL that apply.*
  • Do you know for CERTAIN if your allergy is to Lecithin (found in Egg Yolks & Soy Beans)?
  • Other Allergies? (Examples: Seasonal & Foods)*
  • Do you have any Prosthetic Joints (Joint Replacements such as hip or knee)?*
  • Does your Physician advise taking an Antibiotic prior to a Dental Procedure?*
  • Are you on an Antibiotic now?*
  • Do you have Diabetes Now or In the Past?*
  • Type of Diabetes:
  • How do you Monitor & Manage Blood Sugar Levels? Please check all that apply.
  • Diabetes: Medical Conditions Related to. Please check all that apply.
  • Diabetes Testing HbA1C (A1C or glycosylated hemoglobin):
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  • Are you on any Diabetes Medications?
  • Diabetes Medications:
  • Cancer or Tumors - Now or in the past*
  • Radiation Treatment to the Head or Neck area?*
  • OLD Bone Retention (Density) Infusions / Treatments? (Examples: Zometa or Xgeva)
  • Are you currently on any Cancer or Tumor Medications?
  • OLD Cancer/Tumor Medications
  • HEART CIRCULATORY: Please Check ALL that apply.*
  • Are you taking any Blood Thinners / Anticoagulants (Coumadin, Plavix, Xarelto, Eliquis, Aspirin, Aggrenox) ?*
  • Common Blood Thinners: Please check all that apply
  • Are you taking any Other Medications for Heart / Circulatory? Examples: Bood Pressure Medications*

  • Since the patient is taking a blood thinner/anti-collagulant, Medical management/clearance must be obtained before an oral surgery procedure can be performed.

    We have a form for either you to complete or the physician. This way we will have medical involvement as to the stopping and restarting of medications or directions to not make any medication changes. Most importantly we will have medical approval to proceed with an in-office procedure.

    This form is located on our website dentalsurgerymd.com. If you have any questions please call our office.

  • Aspirin (or Baby Aspirin) causes bleeding issues.

    If you are taking either Aspirin or Baby Aspirin on your own (not prescribed by your physician) please stop taking it 5-7 days before your procedure. If you have any questions please consult your medical doctor. 

  • OLD Blood Thinners & Heart & Circulatory Medications: Include Aspirin & Baby Aspirin
  • Coumadin (Warfrin) - INR Last Test Results:
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  • Does your physician ALLOW the use of Epinephrine / Adrenaline (Used in Local Anesthetics)?*
  • Medications for Bone Density (including Osteoporosis) - Now or in past*

  • Patients who are currently taking or have taken bone density medications need medical clearance before having oral sugery. We have a medical management/clearance form on the website. The website is dentalsurgerymd.com.

  • Medications for Bone Density (including Osteoporosis) - Now or in past
  • OLD Bone Density Medications: Please include all taken ever. If stopped, please note when.
  • RESPIRATORY: Do you have ANY of the Following? Please Check ALL that apply.*
  • Are you taking or have been recently on any Steroids such as Prednisone?*
  • Do you take any Respiratory Medications?*
  • OLD Respiratory Medications: If already added above there is no need to repeat it here. Include Allergy medications & Steroids (such as Prednisone/Cortisone) if taking.
  • Do you have a "Rescue Inhaler"? If YES please bring it to your surgical appointments.
  • Have you ever Smoked / Smoking (including vaping or Juulling ) or used/using chewing or smokeless tobacco. *
  • Smoking Details:
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  • Have you used cannabis (Marijuana, Pot, or THC) in the past year?*
  • Check all that apply:
  • OTHER CONDITIONS & PROBLEMS: Have you EVER had ANY of the Following? *
  • Do you take any medications for weight loss that are considered GLP-1 receptor agonists?*
  • GLP-1 receptor agonist medications - for weight loss*

  • CAUTION IF ON A GLP-1 MEDICATION:

    POTENTIAL Pulmonary Aspiration During General Anesthesia or Deep Sedation: These medications delay gastric emptying. There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations.

    If on one of these medications and anesthesia is used there will be modified instructions for fasting the day before surgery.

    Our office will go over this with the patient or family of the patient to assure a safe surgery.

  • Some Health Problems or Conditions may require Medical Management or Clearance for an In-Office Oral Surgery Procedure. 

    Please detail your problem or condition. If Medical Managment or Clearance may be necessary.

    We have a medical management/clearance form on the website.

    The website is dentalsurgerymd.com.

  • DENTAL: Do you have ANY of the Following? Check ALL that apply.*
  • OLD: Do you take any Prescription Medications?
  • OLD: Do you have a List of Medications to Provide?
  • OLD Current Prescription Medications: If already added above there is no need to repeat it here.
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  • Are you taking any Natural / Herbal / Vitamins / Supplements (Including Diet Supplements) or Remedies?
  • Please indicate if you are taking any of the following: You can add at the bottom. Some Supplements may cause blood pressure instability under anesthesia or increased bleeding from surgical procedures. Certain medications need to be stopped 7 days before surgery.
  • Is there ANY chance that you may be Pregnant?
  • What Trimester are you in?
  • Are you Nursing?
  • Do you take Birth Control or Hormone Replacement Therapy (HRT)?*

  • WARNING! ANTIBIOTICS (example: penicillin) may render Birth Control Pills ineffective. Consult your obgyn or physician for advise and alternative birth control.

  • Do you have a disease, condition, or problem not listed previously?*
  • Do you have plans to Travel or Fly soon?*

  • Travel plans need to be considered when scheduling oral surgery procedures. Often we try to have patients nearby for a week or longer after a surgery in case there is a post operative concern. Please discuss this with our office when scheduling. 

  • Are you an Athlete?*

  • Athletic activity may need to be avoided after oral surgery.

    For some surgerical procedures raising the head blood pressure may cause bleeding or lose of a blood clot - we generally as for patients to avoid excercising, lifting weights, or even bending down for 48 hours. 

    Other sugical procedures may require refraining for an even longer period but, not typically so.

    Some sports may involve the potential for head interaction/contact. Please let us know if you are involved in a sport that may fit this discription.

  • Are you a Swimmer?*

  • Swimming should be avoided for a minimum of 3 days after oral surgery. Dr. Alman would prefer 5 days. The concern is questionably clean water and open wounds. Please call our office if you have any questions.

  • Do you play a Wind Instrument or are a Singer?*

  • Both wind instruments and singing involve using the muscles of the mouth.

    Some procedures especially the removal of several wisdom teeth may cause jaw stiffness and or muscle fatigue or soreness.

    Dr. Alman generally asks patients to avoid both playing a wind instrument or singing for a week after surgery. Other sugical procedures may require refraining for an even longer period but, not typically so.

    Please call our office if you have any questions.

  • Do you have DENTAL Insurance?

  • DENTAL INSURANCE:

    Oral surgery procedures may be covered by dental insurance. Dr. Alman is NOT a perferred provider for any insurance plans. HMOs & Discount Plans do not have any out of network benefits.

    If you have coverage has out-of-network benefits we will be pleased to assist by filing a claim on your behalf. We are filing for you to be reimbursed according to the out-of-network benefits available.

  • Dental Insurance Member/Subscriber?
  • Dental Insurance Subscriber Information:
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  • Dental Insurance:
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  • Are the Wisdom Teeth Impacted? Impacted means buried in bone - If the wisdom teeth are "out" and visible they are considered Erupted.
  • Does the patient have Medical Insurance through a FEDERAL employee insurance plan? Examples: GEHA, and Blue Cross Blue Shield.

  • MEDICAL INSURANCE - FEDERAL EMPLOYEE PLANS:

    Impacted Wisdom Teeth are STILL covered under many FEDERAL MEDICAL INSURANCE plans. It is extremely rare for a medical plan to cover impacted wisdom teeth and other oral surgery - so this is a great benefit! 

    Dr. Alman is NOT a perferred provider for any insurance plans. However, we do help by filing for you to be reimbursed according to the out-of-network benefits as available. For wisdom teeth, we have been finding that the payments have been up to 85% or more of our fees! If you have dental insurance in addition to the medical insurance we will file this as well.

    • Some Federal plans require 2 or more impacted teeth in order for the medical insurance coverage to apply.
    • Erupted teeth are not covered under the medical plans - instead once erupted, the teeth are only covered under a dental plan.
    • Anesthesia will also be covered if the teeth are impacted (2 or more).
    • Another great benefit is that the medical insurance does not have a annual maximum that dental plans have.
    • Please call your insurance company to verify your benefits. We will provide an estimate with the codes to assist you. However, we find that asking "Is impacted wisdom teeth covered under my medical plan?" is sufficient.

     

  • Insurance: Please indicate all that apply

  • MEDICARE PART B:

    Dr. Alman does not participate with any insurance companies as a prefered provider including with MEDICARE PART B. He has signed a letter with Medicare to Opt-Out of Medicare. This means that patients need to be informed that they will not receive benefits from Medicare and the office is not allowed to file to Medicare.

    Instead, the patient is asked to sign an OPT-OUT LETTER OF AGREEMENT which acknowleges that the office does not participate. 

    We will still need a copy of the medicare card to send to the lab for them to file to Medicare should a biopsy be performed.

  • Medical Insurance Member/Subscriber:
  • Medical Subscriber Information:
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  • Medical Insurance:
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  • Is there a Secondary Medical Insurance?
  • Secondary Medical Insurance Member/Subscriber
  • Secondary Medical Subscriber Information:
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  • Secondary Medical Insurance:
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  • HMO INFORMATION:

    Dr. Alman does not participate NEED TO CHANGE!

     

     

     

    with any insurance companies as a prefered provider including with MEDICARE PART B. He has signed a letter with Medicare to Opt-Out of Medicare. This means that patients need to be informed that they will not receive benefits from Medicare and the office is not allowed to file to Medicare.

    Instead, the patient is asked to sign an OPT-OUT LETTER OF AGREEMENT which acknowleges that the office does not participate. 

    We will still need a copy of the medicare card to send to the lab for them to file to Medicare should a biopsy be performed.

  • General Practitioner (GP)
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  • Diabetes Physician:
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  • Bone Density Physician:
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  • Heart Circulatory Physician:
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  • Blood Thinners / Anticoagulants Prescribing Physician (if not the Heart/Circulatory Physician):
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  • Cancer / Tumor Physician:
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  • Respiratory / Allergist Physician:
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  • Other:
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  • Payment for the Services will be paid by: (AMEX is not available)
  • Financial Agreement:
  • Health History:
  • Non-Participation: Medical & Dental Insurance Plans:
  • Non-Participation:
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  • Overall Form Acknowledgment:
  • Privacy:
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  • PHOTOS: As an option - You may also take photos of your ID, referral, and other information.
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  • Should be Empty: