Example: December 15, 2012

5. Best Phone #:

History and Physical:

Recreational drug use, overdose with medications, or excessive alcohol consumption or tobacco use can adversely affect the liver function and body immune system, in addition to other body organs, this can have a negative affect on healing and post procedural complications and potentially can be life threatening. Please disclose all this information with your surgeon before hand.

Past Medical History

Answer following with Yes or No, for Yes answer please explain the condition.

Failure of disclosure can lead to complications in bone healing (Osteonecrosis of the jaw bone) which are very difficult to treat and is a serious side effect of these medications.

Items # 39 to 42 below are for females only

In Regards to Birth Control Pills: Antibiotics are commonly prescribed during your surgical management Antibiotics can decrease the efficacy of the birth control pill leading to pregnancy. It is recommended that a second alternative form of birth control be used for the full cycle (month) if pregnancy is not desired.

Example: December 15, 2012

  • NextGen Oral MaxilloFacial & Reconstructive
  • Surgery Center
  • Oral and Facial Cancer Specialists
  • Facial, Head & Neck Surgery
  • Microvascular Reconstructive Surgery