Welcome to the practice of Paolo Incampo, DMD and Associates
|
|
|
- Laura Evans
- 8 years ago
- Views:
Transcription
1 Welcome to the practice of Paolo Incampo, DMD and Associates We have been providing exceptional and comprehensive dental treatment to families of the greater Merrimack Valley community for over a decade. Whether it is in the area of general dental care and prevention, cosmetic dentistry or prosthodontics and restorative dentistry our ultimate goal is to deliver first class service with state of the art treatment for each and every patient. We are able to meet all of your dental health needs and do not believe that one size fits all. As our patient, you become our partner in determining the appropriate treatments for your unique needs and we believe in recommending treatment to correct issues before they become problems. Our staff is one of our greatest assets. Each of our friendly, highly trained team members provides personalized attention to each of our patients by delivering compassionate, patient-focused care. For patients in need of restorative, aesthetic or implant dentistry, Dr. Incampo is a highly trained, certified prosthodontist who is renowned for his artistic skills and attention to detail. As a result, many dentist and specialists rely on Dr. Incampo for their own cosmetic and restorative dentistry needs. Dr. Incampo is a respected prosthodontist who renews smiles through comprehensive restorative care. As an experiences and highly trained specialist, he uses modern technology and materials to deliver premium dental restorations and replacement teeth for smiles that last. We are looking forward to meeting you at your appointment. In the meantime, if there is anything additional you may require from us to assist in making your visit exceptional please do not hesitate to contact us at Sincerely, Dr. Paolo Incampo
2 TIME 02:43 PM PATIENT REGISTRATION DATE 4/21/2015 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party ( if someone other than the patient ) Last Name: Preferred Name: Middle Initial: First Name: Last Name: Middle Initial: Home Phone: Pager: Work Phone: Ext: Cellular: Birth Date: Soc Sec: Drivers Lic: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient Information City: State / Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth Date: Age: Soc Sec: Drivers Lic: I would like to receive correspondences via . Employment Status: Section 2 Section 3 Full Time Part Time Retired Student Status: Full Time Part Time Medicaid ID: Employer ID: Carrier ID: Pref. Dentist: Pref. Pharmacy: Pref. Hyg: Primary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Ins. Company: Rem. Benefits: Rem. Deduct: Secondary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Ins. Company: Rem. Benefits: Rem. Deduct:
3
4 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES We are required to provide you with a copy of the Notice of Privacy Practices (NPP), which states how we may use and or disclose your health information. Please sign this form, which indicates receipt of the notice. You may refuse to sign this acknowledgement. Patient s Name: Date: You may use your mark or a stamp if you are unable to sign. I,, have received a copy of the Privacy Notice. Printed or typed name of person receiving notice. Signature of Patient/Legal Representative Date: Provider Notes: I gave a copy of our Privacy Notice. Patient / Legal Representative However, he/she declined to sign it. Employee/Witness Signature Date:
5 Financial Agreement for Treatment Payment is due in full at time of treatment unless prior arrangements have been approved by this office. If this office accepts my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payments and deductibles that my insurance does not cover. I hereby authorize payment directly to Dr. Paolo Incampo of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company. Signature Date
6 Informed Consent for General Dental Procedures You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist s advice and recommendations regarding medication, pre and post treatment instructions, referrals to the other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Please read and initial the items below and sign at the bottom of the form. 1. Treatment to be Provided I understand that during my course of treatment that following care may be provided: -Examinations -Preventive Services -Restorations -Crowns -Bridges -X-rays -Study Models -Photographs 2. Drugs and Medications I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). 3. Changes in Treatment Plan I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary. 4. I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable. Patient Signature Date
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
Facts About Dentists and Insurance
Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers
Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
PATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
PATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
California Pain Consultants - PATIENT REGISTRATION FORM
Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:
Faculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital
OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)
OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that
Delta Dental of New Jersey
Delta Dental of New Jersey With Delta Dental, You Get These Important Features Comprehensive preventive, basic and major dental coverage Choice of two excellent plans... so you can select the one that
Central Carolina Dental Center Phone: (919) 777-7780 Dental Hygiene Program Fax: (919) 777-7788 900 S. Vance Street; Suite 220 Sanford, NC 27330
Central Carolina Dental Center Phone: (919) 777-7780 Dental Hygiene Program Fax: (919) 777-7788 900 S. Vance Street; Suite 220 Sanford, NC 27330 Please Print All Information: Name of Patient: Sex: Male
Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip
Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )
LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
Patient Demographic Form
Patient Demographic Form New Patient Returning Patient Primary Care Physician (PCP) Name: Patient Name: Last Name First Name MI Address: P.O. Box City: State: Zip: Cellular Number: Home Number: Work Number:
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:
Tell Us About Your Child. Dental History. Medical History
Tell Us About Your Child Today s Date Social Security# Child s Name: Child s Birthdate: Last First MI Child s Age: Nickname Male Female School Grade Child s Home Address: Who may we thank for referring
Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity
PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:
To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye
Patient Registration Form
900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:
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
I have received a copy of the Notice of Privacy Practices True Health.
Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A
Dr. Brett Haderlie, D.C. Patient Information (Please Print)
CONNECT CH I ROPRAC TIC Dr. Brett Haderlie, D.C. Patient Information (Please Print) Thank you for choosing our practice for your chiropractic needs. Name SS/HIC/Patient ID# Address City State Zip Birthdate
Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (
Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.
FAMILY PRACTICE PATIENT REGISTRATION FORM
FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First
8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:
Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:
Signature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
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
The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME
The McGregor Clinic Inc. Patient Registration/Demographic Form Patient Enrollment PLEASE USE LEGAL NAME First Name: MI: Last Name: of Birth: Sex: SS#: Marital Status: Single Married Separated Divorced
Advanced Solutions Pain Management
Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:
REGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred.
Signature Preferred Pharmacy Referral Info Emergency Contact Guarantor Information Patient Information Name (Last, First, MI) REGISTRATION FORM Today's Date Street Address City State Zip Gender M F SSN
New Patient Intake Package
CORE Physical Therapy 1255 S State St, Suite 7 Dover, DE 19901-6932 Phone: (302) 734-0100 Fax: (302) 734-0101 New Patient Intake Package - Welcome Letter - Consent Form - Appointment Contact Preference
Physical Occupational and Speech Therapy Patient Information Sheet
Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY
When you arrive for your first appointment, please bring the following with you:
115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
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
Teena Paris DDS Program Coordinator
MISSOURI DONATED DENTAL SERVICES (DDS) In response to your recent inquiry about the availability of free or low-cost dental care, we are pleased to provide the following information about the Donated Dental
ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
Patient Registration Please Print Patient Name Last First Middle
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
RESOURCE MEMO #HE17 Date: July 30, 2008 RE: Free Dental Care Application
United Cerebral Palsy Association of Greater Indiana, Inc. 107 N. Pennsylvania St., Suite 804 Indianapolis IN 46204 800-723-7620 Fax 317-632-3338 http://www.ucpaindy.org RESOURCE MEMO #HE17 July 30, 2008
Sincerely yours, Rev. 06.10
Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
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,
Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL
Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based
PROFESSIONAL GROUP PLANS, INC.
PROFESSIONAL GROUP PLANS, INC. Specializing in Employee Benefits Horizon Healthcare of New York New Business Submission Checklist Small Group Sold Case Checklist Employer Application Copy of Sold Proposal
(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
Delta Dental Individual and Family
Delta Dental Individual and Family for the Arkansas Retired Teachers Association DENTAL AND VISION PLANS AT A PRICE THAT WILL MAKE YOU SMILE. WHY DENTAL INSURANCE? To improve your health People with dental
Patient Insurance Information
Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI- CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312- 9310 New Patient Information / Change of Information : New Patient Change
Consent for the use of Private Health Information Informed Consent
Consent for the use of Private Health Information Informed Consent Watertown Dental Care & Dakota Center for Dental Sleep Medicine 600 4 th Street NE, Suite 207 Watertown, SD 57201 Our office operates
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
Thank you for your cooperation.
DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada
WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:
WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel
Dear Patient, If you have any questions about your appointment, please do not hesitate to call us at (910) 791-4755. Welcome to our practice!
Dear Patient, Thank you for choosing Wilmington Hearing Specialists for your audiology care! We are excited to welcome you to our practice and provide the high quality services, products, and attention
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a
Welcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
Flyer Internet Source (Please circle one): Office Webpage Google Facebook Other Insurance Please Specify. Last Name First Name M.I.
Welcome and Thank you for choosing us as your oral care provider! To help us meet all your dental needs, please fill out this form completely. If you have any questions or need assistance, please ask us
Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
If you do not meet at least one of the two criteria above, then you do not qualify for services through the TXDDS program.
Texas Donated Dental Services PROGRAM ELIGIBILITY CRITERIA In response to your recent inquiry about the availability of free and low-cost dental care, we are pleased to provide the following information
PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
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:
Community Health Programs Patient Registration
Community Health Programs Patient Registration Last Name: First Name: Preferred name: Middle Initial: Suffix: Gender: Male Female Former Last Name: Date of Birth: / / Social Security Number: SSN: Mailing
OPTION #2 COMPANION LIFE DENTAL INSURANCE PLAN SELECT ANY DENTIST
OPTION #2 COMPANION LIFE DENTAL INSURANCE PLAN SELECT ANY DENTIST A Dental Plan for Groups of Three or More Covered Services Description SELECT ANY DENTIST Preventive, Basic, and Major services are subject
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:
Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
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
Phone 1(671) 646-3741 Fax 1 (671) 646-3740 278 South Marine Drive, Hengi Plaza, Suite 203, Tamuning, Guam 96913. Dental Plan Application Packet
Phone 1(671) 646-3741 Fax 1 (671) 646-3740 278 South Marine Drive, Hengi Plaza, Suite 203, Tamuning, Guam 96913 Plan: 1023 Plan: 1777 1 year contract for Adult $417.60 1 year contract for Adult $371.52
New Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
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.
21031 Michigan Avenue Dearborn, MI 48124
21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS
If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273
Patient Name: DOB: Soc Sec#: Thank you for choosing Saratoga Cardiology for your cardiac care. We would like to welcome you to our practice. Please complete the attached form for our records and bring
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.
TrueCare Washington. You re not going to drill if you don t have to? THE POLICY PROVIDES DENTAL BENEFITS ONLY.
You re not going to drill if you don t have to? TrueCare Washington Form No. 005IWA(8/14) Policy Form No. 001TRUE-WA(1/14) THE POLICY PROVIDES DENTAL BENEFITS ONLY. Personal care for your individual needs
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
2016 Group Dental Member Handbook. For active employees and retirees BENEFITS. State of Tennessee
2016 Group Dental Member Handbook For active employees and retirees BENEFITS State of Tennessee Revised on 4/19/2016 Welcome! Why is having a good Dental plan so important? Because a healthier smile can
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
How To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
Dental Claim Form HEALTH INSURANCE. 1 of 5 PLEASE COMPLETE THIS FORM USING BLOCK CAPITALS
Dental Claim Form HEALTH INSURANCE PLEASE COMPLETE THIS FORM USING BLOCK CAPITALS INSTRUCTIONS FOR FILING A DENTAL CLAIM 1. Please type or print and include all requested information 2. A separate claim
Your appointment is scheduled for at with Dr. Your arrival time is.
Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half
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.,
Generali Worldwide Health Insurance Dental Claim Form
Generali Worldwide Health Insurance Dental Claim Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. INSTRUCTIONS FOR FILING A DENTAL CLAIM 1. Please type or print
PATIENT INTAKE INFORMATION
PATIENT INTAKE INFORMATION Patient Intake and Worker Compensation / Insurance Information Please have insurance card(s) available for copying Family Physician: Please fill in ALL blanks unless specified
EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550
EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550 NEW PATIENT INFORMATION FORM - PLEASE PRINT LEGIBLY - THANK YOU. PATIENT S NAME DATE
PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#
Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
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
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
Physician Disclosure
Physician Disclosure As required by Section 102.006 of the Texas Occupations Code, a physician must disclose to a patient those arrangements permitted under applicable Texas law whereby such physician
HIPAA PATIENT S AUTHORIZATION
HIPAA PATIENT S AUTHORIZATION THIS FORM IS TO CONFIRM YOUR AUTHORIZATION TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR THE DAILY HEALTHCARE OPERATIONS OF COSMECTIC AND FAMILY DENTAL CENTER (SAMUEL
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
Statement of Understanding
Statement of Understanding By signing this application, I represent that all my answers are complete and accurate to the best of my knowledge and belief and that I understand and agree to the following
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,
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number:
THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)
Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):
CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
TONGUE/LIP TIE PATIENT INFORMATION
TONGUE/LIP TIE PATIENT INFORMATION Today s Date: Patient s DOB: Patient s Name: Parent s Name(s): Main Concerns: Pediatrician s Name: Are you currently working with a lactation consultant? If so, who?
Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -
Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date
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
Community Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State:
Community Health Programs Patient Registration Last Name: First Name: Preferred Name: Middle Initial: Suffix: Former Last Name: Gender: Male Female Date of Birth: / / Social Security Number: Mailing Address: