H. RYAN KAZEMI, DMD

ORAL and MAXILLOFACIAL SURGERY

BETHESDA, MD + WASHINGTON, DC

301.654.7070

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4825 Bethesda Ave., Suite 310
Bethesda, MD 20814
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Home > Your Guide > Plan Your Visit > Online Registration

Online Registration

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Appointment type * Consultation Surgery Same day consult & surgery Follow-up
Please choose * I have made an appointment already (skip to Continue button) I need to make an appointment
Preferred date * (mm/dd/yyyy)
Preferred time * AM PM
Continue

Want to print the forms? Click here

Step 1 - General Info
Step 2 - Medical History
Step 3 - HIPAA

Reason for visit

Teeth extractions Bone grafting Jaw surgery CT scan

Dental implants Exposure of teeth Pain and swelling

TMJ problems Biopsy Follow up
Other

Patient Information

Patient's name *
Patient's E-mail *
Date of birth * / / (MM/DD/YYYY)
Referred by *
Name of your general dentist
Telephone number *
Alternate phone

Street Address *
Address Line 2
City *
State *
Zip Code *
Country
Which is your prefered way to contact? Email Text Cell Home Work

Financial Guarantor Information

If self, check box and click on Continue
Self Spouse Parent Other

Name *
Date of birth * / / (MM/DD/YYYY)
Phone number *
Street Address *
Address Line 2

City *
State *
Zip Code *
Country

Consultation Authorization

All surgeries require an initial evaluation which consists of clinical and X-ray examination, review of treatment options, and important instructions. A consultation may be done on the same day as surgery for some procedures. The consultation fee is due on the day of the appointment and may or may not be covered under insurances. Please initial below to consent for consultation:

Consultation ($125)

X-ray Authorization

Most procedures, including wisdom teeth extractions and dental implants, require a panoramic x-ray for diagnosis. This x-ray must be current (within 6 months of surgery). The x-ray fee is due at the time of service and may or may not be covered under insurances. Please initial below to consent for x-ray:

Panoramic x-ray ($125) Periapical x-ray ($35) Cone Beam CT ($250)

Medical History

Sharing accurate medical history is important for safe delivery of your care.

Patient's name *
Patient's E-mail *
Weight (Lb.)
Height (Ft.) (In.)
Are you currently under care of a physician for any illnesses? No Yes
If Yes - Please list the conditions:
Have you had serious illness, operation, or hospitalization within the past 5 years? No Yes
If Yes - Please explain:
Do you have any of the following? (Please check)

Artificial joint replacement (knee, hip, shoulder, etc) Artificial heart valves Heart murmurs

Serious congenital heart condition Infective endocarditis Damaged heart valves
Do you have or have you had any of the following diseases or problems? (Please check)

Heart disease Congenital heart deformities Angina Heart murmur Bleeding disorders Blood transfusion Emphysema Diabetes Epilepsy Stroke Liver disease Jaundice Rheumatic fever Chemotherapy

Sleep apnea Fainting spells AIDS or AIDS related complex Organ transplants Anemia Depression Anxiety Heart attack High blood pressure Chest pain Irregular heart beat Ankle swelling Asthma Shortness of breath

Lung disease Bronchitis Seizures Immune deficiency Kidney disease Hepatitis Irradiation in head/neck region Anemia Osteoporosis Tuberculosis Thyroid problems Sexually transmitted diseases Breathing/Respiratory problems Cancer
Are you taking or have you ever taken Bisphosphonates (Fosomax, Actonel, Boniva, Aredia or Zometa) for osteoporosis or chemotheraphy for multiple myeloma or other cancers? No Yes
If Yes - please explain when you started and stopped therapy.
Do you currently take any medications? No Yes, I am taking the following medications:
Antibiotics Medications for blood pressure Tranquilizers Insulin

Blood thinners (anticoagulants) Steroids (including prednisone) Ibuprofen (advil, motrin, acetominophen, tynenol) Digitalis
List any other medications:
Do you have any allergies to medications, substances, or materials? No Yes, I have allergy to the following:
Local anesthetics Erythromycin Other antibiotics Barbiturates

Iodine Latex or rubber products Penicillin Clindamycin

Sulfa drugs Aspirin Codeine or other narcotics Other
If Other, please specify
Do you smoke? No Yes
If yes - how much daily?

WOMEN

Are you pregnant or trying to become pregnant? No Yes
Are you nursing? No Yes
Are you taking oral contraceptive / hormonal theraphy? No Yes

About form and information given

Form completed by
(first name) (last name)
Relationship to patient Self Parent Son or daughter Siblings Legal guardian Friend
I certify that I have read and understand the questions 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 surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

HIPAA

Acknowledgement of Receipt of Notice of Privacy Practices (You may refuse to sign this acknowledgement)

I, (full name)
have received a copy of this office's Notice of Privacy Practices
SIGNATURE
(first) (last)
DATE (MM/DD/YYYY)
Verification Image *
* Required fields

Please, complete this form and submit

Reason for visit

Teeth extractions Bone grafting Biopsy Follow up

Dental implants Exposure of teeth Jaw surgery

TMJ problems Cosmetics / Botox Pain and swelling
Other
Patient Information
Patient's name *
Patient's E-mail *
Cell Phone number
Home Phone number
Work Phone number
Which is your prefered way to contact? Email Text Cell Home Work

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