Silver Dental. 621 White Horse Pike, Haddon Township, NJ Mount Holly Road, Burlington, NJ
|
|
|
- Teresa Young
- 7 years ago
- Views:
Transcription
1 Silver Dental Dr. Scott Silver, DMD Dr. Bruce Silver, DMD 621 White Horse Pike, Haddon Township, NJ Mount Holly Road, Burlington, NJ The Financial Aspect of Your Dental Treatment Our primary goal is to provide patients with the highest quality dentistry available, using the latest techniques and materials to ensure long lasting, beautiful results. We realize that this needs to be accomplished while keeping your budget in mind. All costs for your dental care will be discussed in detail so you may plan and budget for your treatment. INSURANCE--For those of you that have dental insurance, we will bill your carrier as a COURTESY TO YOU, with you paying the estimated copay at the time of service. We will assist in claims submissions to obtain payment for your treatment. However, in some instances your insurance company will only send payment directly to you. If that is the case, we ask that you pay in full for your treatment at the time it is performed, and we will be glad to submit the paperwork to your insurance carrier for your direct reimbursement. We will attempt to estimate how your insurance company will pay for your dental services, but we have no way of knowing exactly what they will pay until the claim is ultimately paid. There is no way we can guarantee what your insurance will pay. Please be advised-when your carrier is to pay us directly and if that payment is not received within 90 days of our submitting the claim, that dollar amount will automatically become your responsibility. This amount will be billed to you and is due upon receipt of a statement. APPOINTMENTS--We will make every effort to schedule your appointment at a time that is convenient for you. Appointment times are customized according to your needs. When you make your appointment, please keep in mind that we are reserving that time especially for you. We respect your valuable time and we ask the same consideration from our patients. Cancellations less than 24 business hours prior to your appointment could result in a charge according to the length of your missed appointment. PAYMENT OPTIONS A. Payment in full at initial visit by check or cash. B. Payment in full at initial visit by credit card C. No interest or installment payment arrangements through an outside financial source. Our staff will provide you with information to utilize this fast and simple way for payment of dental treatment. AUTHORIZATION I understand that I am responsible for all cost of dental treatment and authorize payment of dental benefits directly to this office. I hereby authorize this dental office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information I have provided to this office on this form and any other completed and signed by me is correct to the best of my knowledge. I will not hold Dr. Bruce Silver or Dr. Scott Silver or any member of their staff responsible for any errors or omissions that I may have made in the completion of my medical or insurance information. FINANCE CHARGE If I do not pay the entire new balance of my account within 60 days of the billing date, a Finance Charge of 2% will be added to the account for each monthly billing period. In the case of default of payment I promise to pay any legal interest on the balance due, along with any collection costs and reasonable attorney fees incurred to effect collection of this account. I understand and agree to the above Date (Patient/Parent/Guardian) info@silverdental.com Website:
2 WELCOME TO THE OFFICE OF SILVER DENTAL PATIENT INFORMATION Thank you for choosing our practice for your dental needs. Please complete this form in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help. (Please Print) Today s Date Address Name Birthdate First MI Last Address Social Security # Telephone # (H) (W) Do you prefer to receive calls at: Home ( ) Work ( ) Either ( ) Are you: Male ( ) Female ( ) Married ( ) Single ( ) Divorced ( ) Widowed ( ) You or your parent s employer Occupation Business Address Spouse s or Parent s name Work Phone # If you are a student, name of school Address Whom may we thank for referring you to our office? Person to contact in an emergency Phone RESPONSIBLE PARTY Name of person responsible for this account SS# Relationship to patient Home Phone # Address Name of employer Work Phone # INSURANCE INFORMATION Name of insured Relationship to patient Name of employer Work Phone # Birthdate Social Security # Insurance Company Group # INSURANCE: We will bill your insurance company as a COURTESY TO YOU. We will assist in all necessary claims submissions in order to obtain payment for your dental services. You are expected to pay your portion of treatment at the time of service. Your insurance carrier s financial responsibility and your co-payment is only an estimate. Anything not covered by your insurance company will be billed to you and payable upon receipt. Remember the ultimate responsibility for payment is yours. CONFIDENTIAL
3 DENTAL HISTORY Reason for today s visit Former Dentist Date of Last Visit How often do you brush? How often do you floss? Please check any of the following conditions that apply to you: ( ) Bad breath ( ) Grinding teeth ( ) Sensitivity to hot ( ) Bleeding gums ( ) Loose teeth or broken fillings ( ) Sensitivity to sweets ( ) Clicking or popping of jaw ( ) Periodontal treatment ( ) Sensitivity when biting ( ) Food collects between teeth ( ) Sensitivity to cold ( ) Sores or growths in mouth MEDICAL HISTORY Physician Phone # Last visit Please list all medications you are currently taking Are you allergic to any of the following: Aspirin NO ( ) YES ( ) Acrylic NO ( ) YES ( ) Penicillin NO ( ) YES ( ) Latex NO ( ) YES ( ) Codeine NO ( ) YES ( ) OTHER: Women: Are you pregnant? NO ( ) YES ( ) Nursing? NO ( )YES ( ) On birth control pills? NO ( ) YES ( ) Do you have a history of the following? ( ) Anemia ( ) Cough, Persistent ( ) Hepatitis ( ) Rheumatic Fever ( ) Arthritis, Rheumatism ( ) Diabetes ( ) High Blood Pressure ( ) Scarlet Fever ( ) Artificial Heart Valves ( ) Epilepsy ( ) HIV/AIDS ( ) Shortness of Breath ( ) Artificial Joints ( ) Fainting ( ) Jaw Pain ( ) Skin Rash ( ) Asthma ( ) Glaucoma ( ) Kidney Disease ( ) Stroke ( ) Back Problems ( ) Headaches ( ) Liver Disease ( ) Swelling Feet/Ankles ( ) Blood Disease ( ) Heart Problems ( ) Mitral Valve Prolapse ( ) Thyroid Problems ( ) Cancer Describe ( ) Pacemaker ( ) Tobacco Habit ( ) Chemical Dependency ( ) Psychiatric Care ( ) Tuberculosis ( ) Chemotherapy ( ) Radiation Treatment ( ) Ulcer ( ) Circulatory Problems ( ) Hemophilia ( ) Respiratory Disease ( ) Venereal Disease OTHER: AUTHORIZATION I understand that I am responsible for all cost of dental treatment and authorize payment of dental benefits directly to this office. I hereby authorize this dental office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information contained on this form is correct to the best of my knowledge. I will not hold this dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. FINANCE CHARGE If I do not pay the entire new balance of my account within 60 days of the billing date, a Finance Charge of 1.5% will be added to the account for each monthly billing period. In the case of default of payment I promise to pay any legal interest on the balance due, along with any collection costs and reasonable attorney fees incurred to effect collection of this account. SIGNATURE (Patient/Parent/Guardian) Date CONFIDENTIAL
4 Silver Dental Dr. Scott Silver, DMD Dr. Bruce Silver, DMD 621 White Horse Pike, Haddon Township, NJ Mount Holly Road, Burlington, NJ Smile Survey Our office is conducting a survey of our patients. If you would kindly answer a few questions below, it would be greatly appreciated. How do you feel about your smile? If you could change anything about your smile, what would it be? (If you had a magic wand!) Is there anything that would keep you from improving your smile? If so, please explain. Are you familiar with how today s dentistry can enhance your smile? Yes / No Would you like to learn more about how you can improve your smile? Yes / No Your name: Thank You! info@silverdental.com Website:
5 SILVER DENTAL ASSOC. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement**, have received a copy of this office s Notice of Privacy Practices. (Please Print Name) Social Security # (Signature) (Date) For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association All Right Reserved Reproduction and use of this form by dentist and their staff is permitted. Any other use duplication of this form by any party requires the prior written approval of The American Dental Association.
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
PATIENT REGISTRATION FORM
: 610 Professional Dr., Suite 250 Gaithersburg, MD 20879 www.greatsmilesdentalcare.com PATIENT REGISTRATION FORM Great Smiles Dental Care takes your oral health very seriously. To help us meet all your
SUMMERVILLE DENTISTRY
PATIENT REGISTRATION Patient Information: Patient First Name: Last Name: Middle Initial: Preferred Name: Patient is : Responsible Party Policy Holder Address: City, State, Zip: Cell Phone: Work Phone:
How did you hear about our office?
PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Email Employer
Elmwood Dental Center Patient Information Form 1128 Clearview Pkwy Metairie, LA 70001 PHONE: (504) 733-1135
Elmwood Dental Center Patient Information Form 1128 Clearview Pkwy Metairie, LA 70001 PHONE: (504) 733-1135 Welcome! Please print this form, fill it out, and bring it with you when you arrive for your
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
Stanwood Dental Care
Stanwood Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,
Welcome tokentlands Dental Care
Patient Information Welcome tokentlands Dental Care Last Name: First Name: MI: Birthdate: Male Female Marital Status: Single Married Other SSN: Address: Apt. No. City: State: Zip: Home Phone: ( ) Work
Brian H. Jamieson D.D.S. Esthetic Family Dentistry 1533 Grove Street Marysville, WA 98270 (360) 659-3200
Esthetic Family Dentistry 1533 Grove Street Marysville, WA 98270 (360) 659-3200 Welcome to Our Office - Tell Us About Yourself Name Last First MI Title Preferred Name: p Male p Female Address: City State
RIVERTOWN DENTAL CENTER
PATIENT INFORMATION RIVERTOWN DENTAL CENTER DATE PATIENT NAME DATE OF BIRTH S.S.N AGE SEX M F MARRIED SINGLE SEPARATED DIVORCED WIDOWED SPOUSE S NAME ADDRESS CITY ZIP PHONE ( ) CELL PHONE ( ) EMAIL DENTAL
Date Home Phone ( ) Address. City State Zip. Patient Employer/ School Occupation. Employer/School Address Employer/School Phone ( )
Welcome to Dr. Christine Theroux Family and Cosmetic Dentistry! PATIENT INFORMATION Date Home Phone ( ) Name Last Name First Name Middle Initial SS/HIC/Patient ID # E mail Address City State Zip Sex M
Date. Initial. Initial. Minor ADDRESS. Cash ADDRESS
PATIENT NAME IF CHILD: PARENT'S NAME HOW DO YOU WISH TO BE ADDRESSED Single Married RESIDENCE - STREET Separated Divorced Widowed CITY STATE ZIP TELEPHONE: RES. EMAIL ADDRESS PATIENT/PARENT EMPLOYED BY
Name: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
PATIENT INFORMATION Thank you for choosing us as your dental care provider. We look forward to caring for you! Patient Information: Patient Name (First Middle Initial Last): DOB: / / SS#: / / Driver s
NEW PATIENT WELCOME PACKET PATIENT INFORMATION
6511 Campbell Boulevard Lockport, New York 14094 Phone: (716) 625-4129 Fax: (716) 625-4491 www.keepsmiling.us NEW PATIENT WELCOME PACKET Welcome and thank you for selecting Marian C. Pilecki, DDS, and
New Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is
Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is our main objective. You can rest assured in knowing that Dr. Tomack and Dr. Behrens have your best interest
General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine
PO Box 297 Hedgesville, WV 25427 304 754-8803 KenBarneydds.com General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine WELCOME TO OUR PRACTICE Welcome to the office of Dr. Kenneth C.
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
Nearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
Patient Information. Referral Information Name of person or Doctor referring you to our practice:
Patient Information Patient First Name: Middle Initial: Last Name: Preferred Name: Address: City/State: Zip: Home Phone: Work Phone: Cell Phone: Sex: Male Female Marital Status: Married Single Divorced
Emergency Contact Phone # Nearest relative not living with you: Name Address City/State/Zip Phone#
Patient name: Age Male Female of birth Social security # - - Married Single Child (under 14) Address Apt # City State Zip Telephone numbers: Home Work Cell Phone Email Address Best way to contact you Legal
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
ADULT DENTAL HISTORY I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE. 1. Purpose of initial visit?
ADULT DENTAL HISTORY 1. Purpose of initial visit? Doctor s Notes 2. Are you aware of any dental problems?... If yes, please explain 3. How long since your last dental visit? 4. What was done at that time?
Patient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
CONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
Welcome to Seattle Smiles Dental
Welcome to Seattle Smiles Dental The Puget Sound Plaza 1325 4 TH Avenue, Suite 1230 Seattle, Washington 98101 TEL: 206.624.1773 FAX: 206.624.2268 info@seattlesmilesdental.com MISSION Our mission is to
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949 Thank you for choosing Lanier Chiropractic and Rehabilitation! It is our desire
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address City, State, Zip: Home Phone: Work Phone: Cell Phone: Birth Date: Age: Sex: Male Female Soc. Sec. #: Occupation: Employer: Marital Status:
Patient Information. Middle Name Last Name Preferred Name è. Home Address City State Zip è
. Patient Information Mr. Mrs. Ms. Dr. Male Female Single Married Divorced Widowed First Name Middle Name Last Name Preferred Name Home Address City State Zip Social Security Number Drivers License Number
Address City State Zip. Cell Phone# Home# Work# Date of Birth / / Age Social Security# - - Sex: Male / Female. Driver s License# State
3191 Maguire Blvd, Suite #251 Orlando, Florida 32803 407-894-1451 phone 407-894-5656 fax PATIENT INFORMATION Legal Name of Patient Nickname Address City State Zip Cell Phone# Home# Work# Date of Birth
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
Welcome to Dr. Moritis Dental Office
Welcome to Dr. Moritis Dental Office Patient Information First Last M.I. Address City State Zip Home Phone Work Phone Cell Phone Email Social Security # Birth date Gender M F Marital Status Single Married
Office Hours: Monday - Thursday 8:00 A.M. 5:00 P.M. New Patient Exams & Cleanings:
We want to provide you with the best dental care possible in an efficient and timely manner. Please take a moment to review our office policies to help us achieve our goals in serving you. If you are a
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
Galerie Dental Care. Patient Information. Emergency Contact Relationship: Phone:
Galerie Dental Care Patient Information Date: Patient Name: Last First Middle Initial (Preferred Name) Gender: Birth Date: Marital/Family Status Address: Street Apartment # City Province Postal Code Phone
Welcome to our Practice! Thank you for choosing our office for your dental care!
Welcome to our Practice! Thank you for choosing our office for your dental care! We are dedicated to providing you and your family with the highest quality of care, using state of the art treatment in
MICHAEL D BROOKS, DMD, MS, PLLC MICHAEL J BOWMAN, DDS, MS, PLLC PATIENT INFORMATION RECORD DENTAL INSURANCE
PATIENT INFORMATION RECORD NAME DATE DATE OF BIRTH SEX SOCIAL SECURITY HOME ADDRESS HOME PH EMAIL CITY STATE ZIP EMPLOYER OTHER PH DENTAL INSURANCE PRIMARY SUBSCRIBER NAME SOCIAL SECURITY # DATE OF BIRTH
SHREVEPORT-BOSSIER FAMILY DENTAL CARE
SHREVEPORT-BOSSIER FAMILY DENTAL CARE Patient's Name: Patient's Birthdate: (FIRST, MIDDLE, LAST) Patient's SSN #: Patient's Email Address: _ Patient's Phone #: Home:_ Cell: Work: Patient's Address: Patient's
Patient s Name First MI Last. Please let us know if you have a nickname or preferred name by which you wish to be called.
Today s Date / / Patient s Name First MI Last Please let us know if you have a nickname or preferred name by which you wish to be called. _ Sex M F Date of Birth / / Single Married Widowed Divorced Home
Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
375 Sixth Street Dover, NH 03820 Tel (603) 749-0636 www.howarddental.com
375 Sixth Street Dover, NH 03820 Tel (603) 749-0636 www.howarddental.com Hello from JD Howard Dental! On behalf of all the staff, we welcome you to our office. We are happy that you have selected us to
We look forward to meeting you. Sincerely, Bradley A. Blair, DDS and Staff
Bradley A. Blair, DDS Comprehensive Dentistry Esthetic, Restorative & Preventive 1101 Norton Rd, Galloway, Ohio 43119 614-878-8303 e-mail: bblairdds@rrohio.com www.blairdental.com Welcome to our office!
Scheduling. Patient Privacy. Financial
Office Policies Brush Dental Care Brandon Kent Farrell, DDS, PA 414 Chestnut Street (Suite 301) Wilmington, NC 28401 Phone: 910-762-1212 Fax: 910-762-1226 Email: wilmington@brushdentalcare.com Scheduling
NEW PATIENT REGISTRATION
Welcome! NEW PATIENT REGISTRATION Thank you for choosing. We are committed to providing every adult and child with the highest quality oral healthcare in the most gentle, efficient manner possible. Remember,
UH Health Center Dental Office 100 UH Health Center, Building 525 713-227- 6453 (main) / 713-783- 2910 (fax) Patient Information
Name: Address: City, State, Zip: Email: SSN: PeopleSoft Number: Electronic Signboard Health Center Website Email Blast Bus Stop Signage Event Table (Which event: ) Is patient own responsible party? Yes
Welcome to Northborough Family Dental
Date: Patient Information: Welcome to Northborough Family Dental Name D.O.B. SS# Address Apt Town State Zip Marital Status Home Phone Cell# Other Email Employer Work Phone EMERGENCY CONTACT: Name Phone
Rancho Penasquitos Dental Center
Rancho Penasuitos Dental Center New Patient Pre-Appointment Check-List Welcome to our practice. We want to make sure your first visit to our office is an exceptional one. To help us meet your expectations
For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure.
FINANCIAL POLICY For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure. METHODS OF PAYMENT Acceptable methods of payment are cash,
Our Commitment to You
For your convenience you may use your keyboard and mouse to complete this form. Our goal is to help you achieve and maintain excellent dental health. The better we communicate, the better we can care for
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:
Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social
karrdds.com 1243 Joliet St. Dyer 219.322.7610 1881 Greenwood Dr. Crown Point 219.488.2410 kids@karrdds.com PATIENT INFORMATION GUARDIAN INFORMATION
1243 Joliet St. Dyer 219.322.7610 1881 Greenwood Dr. Crown Point 219.488.2410 kids@ PATIENT INFORMATION / / Email Patient Name (Last, First) Sex: M F Age Birthdate / / Home Phone Number ( ) Best phone
welcome REGISTRATION SummerHills Dental DENTAL INSURANCE 1ST COVERAGE DENTAL INSURANCE 2ND COVERAGE Age Date Patient s Name Date of Birth Male Female
welcome Age Date Patient s Name Date of Birth Male Female Last First If Child: Parent s Name How do you wish to be addressed Single Married Separated Divorced Widowed Minor Residence Street City State
What is the best way to contact you?
IDENTIFICATION PATIENT REGISTRATION Today's Date PLEASE PRINT CLEARLY AND FILL IN ALL THE SPACES BELOW Patient Name (Last, First, Middle Initial): Date of Birth Social Security # Mailing Address City State
Chad Biggio D.D.S. 8480 Bluebonnet Blvd Ste. E Baton Rouge, LA 70810 (225) 767-4491 PATIENT INFORMATION
Chad Biggio D.D.S. 8480 Bluebonnet Blvd Ste. E Baton Rouge, LA 70810 (225) 767-4491 PATIENT INFORMATION Patient s Name: First Middle Last If Child: Parent or Guardian Name: Relation: Address: Apt #: City:
Lake City Cosmetic Dentistry 3340 NE 125 th Street Seattle, WA 98125 206-363- 6868
Lake City Cosmetic Dentistry 3340 NE 125 th Street Seattle, WA 98125 206-363- 6868 ACKNOWLEDGMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICE I acknowledge that I have received a copy of the Statement
Welcome. We are pleased to welcome you to our practice. Please take a few minutes to complete this form. Patient Information. Name Date.
Welcome We are pleased to welcome you to our practice. Please take a few minutes to complete this form. Patient Information Name Date Address City State Zip Phone home Office Cell Male Female Birth date
Patient Registration
13925 Coalfield Commons Place Midlothian, VA 231114 Ph. 804.897.3345 Fax. 804.897.3341 Patient Registration Welcome to our office. We appreciate the confidence you place with us to provide dental services.
Are you in good health Yes No Chronic fatigure/night sweats. Yes No
Healthy Smiles Health History Patient's Name Are you in good health Yes No Chronic fatigure/night sweats. Yes No Has there been any change in your health Do you have implants? within the past year.. Yes
Welcome To Our Office!
Last Name: Welcome To Our Office! First name(s): We are delighted that you ve chosen Kids Dental Center to take care of your child s dental needs. Please take a moment to answer the following questions
Part Four: Who is Accompanying the Child Today? Part One: Tell Us About Your Child. Part Five: Referral. Part Six: Person Responsible for Account
Kee Kwak, DDS Grace E. Smart, DDS, MS, PC 2426 Beltline Road Garland, TX 75044 New Patient Health History Form Print this form, complete all information, and bring it with you on your first visit to our
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
Payment Is Expected At Time Of Each Visit Please Check Method of Payment
Rachel Mahoney, DMD 21727 76th Ave West Suite G Edmonds, WA 98026 Office (425) 967-7272 www.mahoneyfamilydentistry.com Fax: (425) 967-7262 ank you for trusting your child with our o ce. In order to serve
Welcome to Central Florida Foot and Ankle Center
Welcome to Central Florida Foot and Ankle Center PATIENT INFORMATION Patient Name Address City State Zip Mailing Address City State Zip SS# DL# E-Mail Sex M F Age Birth Married Widowed Single Minor Separated
Title Suffix Sex: M F Date of Birth Age: City State Zip. PRIMARY: Insurance Type : Medical Dental SECONDARY: Insurance Type : Medical Dental
PATIENT REGISTRATION FORM Page 1 of 1 I. Patient Information Marital Status Single Married Family Dentist: Family Physician: Title Suffix Sex: M F of Birth Age: Last «aplname» First MI Nickname Address
Thank you for visiting Albion Dental Center. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Medical Alert For Office Use Thank you for visiting Albion Dental Center. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient Information Name LAST FIRST
PATIENT REGISTRATION. First Name: _ Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: _. Address: _ Address 2: _
TIME 145 PM DATE 10/13/2008 10: Chart 10: PATIENT REGISTRATION First Name: Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: o Responsible Party Responsible Party (Wsomeone other than
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
Nondiscrimination in Services Policy
The faculty, students and staff at the Herman Ostrow School of Dentistry of USC Faculty Practice are committed to ensuring that you receive the highest quality of care and service. We have developed a
MEDICAL HISTORY. PATIENT S NAME Last First Initial Date of Birth CIRCLE THE APPROPRIATE ANSWER COMMENTS MED. ALERT ANEST. 1.
PATIENT S NAME Last First Initial Date of Birth CIRCLE THE APPROPRIATE ANSWER 1. Physician s Name COMMENTS Address 2. Are you under a physician s care?...yes NO Since when Why? 3. When was your last complete
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Patient Information. Middle Name Last Name Preferred Name. Home Address City State Zip. Social Security Number Drivers License Number Date of Birth
Patient Information Mr. Mrs. Ms. Dr. Male Female Single Married Divorced Widowed First Name Middle Name Last Name Preferred Name Home Address City State Zip Social Security Number Drivers License Number
Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com
1 Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com DEMOGRAPHICS & INSURANCE Patient Information Name: (First) (MI) (Last) SS#: DOB: Sex: Male Female Address:
Welcome to Happy Teeth Dental Care!
Happy Teeth Dental Care Registration Packet Welcome to Happy Teeth Dental Care! Thank you for choosing our office for your dental needs. We look forward to meeting and working with you! Happy Teeth Dental
Kids Smiles Children s Dental Office
Dear New Patient Parents: Kids Smiles Children s Dental Office Welcome to Kids Smiles! Thank you so much for coming in today. We hope you have an enjoyable visit. Kids Smiles was founded on Martin Luther
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
PATIENT INFORMATION. Office Location:
Date: PATIENT NAME (Last, First M.I.): PATIENT INFORMATION (Please complete all sections) Office Location: DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
Airport Way Dental Care
Airport Way Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
WELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
PATIENT INFORMATION PATIENT NAME (LAST, FIRST, MIDDLE) SEX DOB MAILING ADDRESS CITY STATE ZIP SSN
PATIENT INFORMATION PATIENT NAME (LAST, FIRST, MIDDLE) SEX DOB MAILING ADDRESS CITY STATE ZIP SSN STREET ADDRESS (IF DIFFERENT FROM ABOVE) CITY STATE ZIP HOME PHONE NUMBER EMPLOYER CELL PHONE NUMBER WORK
Mother Stepmother Guardian. Your Child. Father Stepfather Guardian. Parent s Marital Status. Primary Dental Insurance. How Did You Hear About Us?
www.hendersonvilledentalspa4kidz.com Your Child First MI Last Preferred Sex Age School Grade Child s Home Address City State/Prov. Zip/P.C. _ Phone Primary Dental Insurance 264 New Shackle Island Rd.,
The following is our policy.
Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality dental care, so that you may attain optimal oral health. Everyone benefits
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400
PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400 Patient Information as of (todays date). Please print legibly and
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
Smiles at Summer Hill Dental and Summerlyn Dental Care
Smiles at Summer Hill Dental and Summerlyn Dental Care New Patient Interview 1. Would you be willing to tell me why you decided to select a new dental office and why you choose Summer Hill/ Summerlyn Dental
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
Patient Information (please print cleary)
Patient Information (please print cleary) Patient Name Male Date of Birth (mm/dd/yy) Social Security Number Female Address City State Zip Code Home Phone Number Cell Phone Number Email Address Employer
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
We would like to take this opportunity to thank you for wanting to become a patient at Thomas E. Langley Medical Center s Dental Department.
Dear New Dental Patient(s) We would like to take this opportunity to thank you for wanting to become a patient at Thomas E. Langley Medical Center s Dental Department. The following packet will need to
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions