First registration Personal InformationMedical InformationPatient Consent Personal Information Select Platinum Dental Surgery Branch * Ikosi KetuLagos IslandIkejaOther Select Platinum Dental Surgery Branch Date of First Visit First Name * Last Name * Date of Birth * Gender * Male Female Are you currently Pregnant Nursing None Have you experienced any complications during pregnancy? Gestational Diabetes Mellitus (GDM)PreeclampsiaAnemiaHyperemesis GravidarumUrinary Tract Infections (UTIs)Preterm LaborPlacenta PreviaPlacental AbruptionHigh Blood Pressure (Gestational Hypertension)Infections (e.g., Group B Streptococcus, CMV)Depression or AnxietyLow Amniotic Fluid (Oligohydramnios)MiscarriageRh Factor Incompatibility ?Other Have you experienced any complications during pregnancy? Has your physician recommended any restrictions or precautions during pregnancy? Yes No Are there any medications or supplements related to your pregnancy/nursing that we should be aware of? Yes No Please list Are you currently breastfeeding? Yes No Are you experiencing any breastfeeding-related issues, such as mastitis or soreness? Yes No Are you taking any lactation-related medications or supplements? Yes No Have you been advised to avoid certain medications while nursing? Yes No Do you experience difficulties with milk supply (low or oversupply)? Yes No Have you noticed changes in your oral health since you started nursing? Yes No Email Address Phone Number Primary Same As Whatsapp? Yes No Whatsapp Number Whatsapp Number # Occupation Marital Status * SingleMarried Religion ChristianityIslamTraditional African religionsAtheistOther Religion Address * Type Of Patients * Type Of patientsREGISTEREDNOT REGISTEREDFAMILY REGHMOPREVIOUSLY REGISTEREDSPECIAL COUPONOther Type Of Patients HMO Details HMO Name * Encounter Date * HMO Plan * Enrollee Number Organization * Enrollee Name * Name HMO Phone Number * Primary I, hereby authorize Platinum Dental Surgery to initiate requests for authorization codes from my Health Maintenance Organization (HMO), as required, for any dental treatments or procedures recommended by the dental team. I understand that it is my responsibility to communicate any preferences or concerns regarding treatment scheduling and to inform the clinic of any changes in my insurance coverage or enrollment status with the HMO. I acknowledge that delays or changes in treatment plans may occur based on factors such as insurance authorization, scheduling availability, and patient preferences. I agree to communicate openly with the clinic and HMO to facilitate timely and appropriate care. Additionally, I acknowledge that any treatment(s) exceeding my coverage will be my sole responsibility until further guidance or authorization is received from the HMO. I certify that I have read and understood the terms outlined in this consent form, and I authorize Platinum Dental Surgery to proceed with the necessary steps to obtain authorization for my dental treatment. I agree To the Above HMO Consent Terms and Condition * I agree Emergency Contacts Name of Emergency Contact * First Name and Last name Relation to Individual * SelectParentSpouseSiblingChildGuardianFriendColleagueRelativePartnerNeighborOther Relation to Individual Emergency Contact Phone Number * Primary Emergency Contact Whatsapp Emergency Person Address Is same as mine? * Yes No Emergency Contact Address plus1 Add Another Contact minus1 Remove Contact Next Δ
