Our Commitment to You
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- Harold Johns
- 8 years ago
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1 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 your needs. If you have any questions, we'll be glad to help! Please print the form and fax, mail or bring it with you to your next appointment. Our fax numbers are Brandon: and Flowood and our mailing addresses are: Brandon Office: 1350 W. Government St., Brandon, MS 39043, Flowood Office: 4802 Lakeland Dr., Flowood, MS 39232, Our Commitment to You We would like to take this opportunity to welcome you to our dental practice. We are pleased that you have chosen us as your dental care team and want you to know that we are committed to providing you with the highest quality dental care in the most gentle, efficient and enthusiastic manner possible! We appreciate your understanding in our efforts to maintain respectful guidelines for our practice to keep the caliber of care and service extraordinary. Treatment Our goal is to build a long-term relationship with you in a relaxed and friendly environment. We are committed to helping you preserve your natural teeth for life and to maintain your oral health at an optimum level. We want to assure you we will be with you every step of the way and welcome any questions you may have. By initialing this section and signing below, you indicate that you understand and agree to these treatment guidelines. Financial Arrangements Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important, life-enhancing care. We are available to answer your questions and assist you in any way we can. We happily accept cash, checks, credit cards (VISA, MC, and Discover) and long term outside financing through Care Credit (o.a.c.). All financial arrangements must be made in advance with a member of our team. Please be prepared to pay any estimated patient portion co-pays at the time treatment is provided. By initialing this section and signing below, you indicate that you understand and agree to these financial guidelines. Insurance We are pleased that you have dental insurance to help you with partial assistance in affording your dental care. As a courtesy, we are happy to assist you in filing the necessary forms to help you receive the full benefits of your dental insurance coverage at no additional cost. Dental insurance is different than most medical insurance plans and it is important to be aware of the following: " Insurance is an agreement between you and your insurance company. The insurance relationship constitutes an agreement between the carrier, the employer, and the patient. Our dental office is not a party to that contract. As such, we can make no guarantee of estimated coverage or payment. Please know that we will do everything possible to see that you receive the full benefits of your policy. By initialing this section and signing below, you indicate that you understand and agree to these insurance guidelines.
2 Appointments We pre-plan and prepare for your visit and hope you have done the same. Your appointment time has been reserved especially for you and we strongly encourage all patients to keep their appointments. When time is lost due to last-minute changes, other patients in need of treatment cannot be seen and your treatment is delayed, often resulting in negative consequences. Should any scheduling changes be required, we require at least 48 hours advance notice to avoid a $65.00 per half-hour cancellation fee. Courtesy Reminder Calls We consider all appointments confirmed when they are made. As a courtesy, we make every effort to remind patients by telephone or prior to their appointment but please do not depend on this courtesy. We have found that with the recent popular use of answering machines, cell phones, pagers, and voice mails, some of our patients may not receive these reminder calls. If we are unable to speak with you directly, your appointment card will serve as confirmation and implies your obligation to be present at that prearranged date and time. By initialing this section and signing below, you indicate that you understand and agree to these appointment guidelines. We appreciate your understanding in our efforts to provide you with an extraordinary dental experience. Patient Signature: Guardian Signature: Date:
3 WELCOME TO OUR PRACTICE We would like to take this opportunity to explain a few of our policies and procedures to you. Appointments Please be on time to your appointments and arrive a few minutes early. This time is reserved for you. If you arrive late to your appointment, there is a possibility that the office will have to reschedule your appointment so as to not inconvenience other patients. Please confirm your intention to arrive for your appointment. You will receive a confirmation call one to two days prior to your appointment. It's important that you confirm this appointment so your appointment date and time is held for you. If you don't speak directly with Reception, please leave a message on the answering machine. It will be picked up the next business day. Our office has a Failed Appointment Fee of $65.00 if 48-hour notice is not given. Failed appointments are a problem for everyone. They delay your treatment and they prevent another patient who may be in need of an appointment to come in your place. To eliminate potential problems, we will be strictly enforcing the following policies: If two appointments are missed or cancelled with less than a 48 hour notice, only same day appointments will be made, subject to availability. If four appointments are missed or cancelled with less than a 48 hour notice, the patient may be, at the practice's discretion, dismissed from the practice. Accounting Our office offers the following arrangements: cash, check, MasterCard, Visa, Discover, outside financing through CareCredit (o.a.c.) and payments split up during the course of treatment- with the payments ending when the treatment is complete. As a courtesy to our insurance patients, we will bill your insurance, however, the balance due is ultimately your responsibility. If, after 60 days, we do not receive reimbursement from your insurance company, the balance will automatically be transferred to you. There is a 1.5% monthly finance charge on any balances that we carry. Please make sure that the insurance information you give us is accurate. We can not be responsible for any incorrect insurance information presented to our office. Due to the large number of dental plans, we cannot guarantee what an
4 insurance company will reimburse. Our calculations are based on the current information each insurance company provides us. If there are any discrepancies in the coverage amounts paid by an insurance company on your behalf, we will either bill you the difference or credit your account for any overpayment. Things you should also know It can't be stressed enough regular exams are essential in maintaining a healthy mouth. If your goal is to maintain your teeth, regular exams must be made a priority in your life. Putting off biyearly exams often leads to worse problems down the line. It is always difficult to see patients decline their biyearly exam for one reason or another because we usually end up seeing them later with more serious problems which require more extensive treatment. It ALWAYS costs more to wait, so your best bet is to get regular exams! Please Help us help you Please check any of the following procedures that you would be interested in talking with our dental team about: 1. Nitrous Oxide - " laughing gas '' to make dental treatment more pleasant 2. Implants - permanently replace missing teeth 3. Braces - straighten teeth with Invisalign or traditional braces 4. Whitening - up to 9 shades lighter in a single appointment 5. Lumineers - Make-over your smile with no shots & no drilling We are pleased that you have chosen our office for your dental needs. We look forward to giving you healthy teeth and caring for you and your family. Patient Signature: Date:
5 welcome PATIENT NUMBER Date 2001 Wisconsin Dental Association (800) I Patient's Name Date of Birth Male Female Last If Child: Parent's Name First Dental Insurance 1st Coverage How do you wish to be addressed Single Married Separated Divorced Widowed Minor Employee Name Date of Birth Residence - Street Employer Name Yrs. Name of Insurance Go. City State Zip Address City State Zip Business Address Telephone Telephone: Res. Bus Program or policy # Social Security No Fax Cell Phone # Union Local or Group Patient/Parent Employed By Present Position Employee Name Employer Name Name of Insurance Go. How Long Held Address Spouse/Parent Name City Telephone Spouse Employed By Program or policy # Present Position How Long Held Social Security No. Union Local or Group Dental Insurance 2nd Coverage State Date of Birth Yrs. Zip Who is Responsible for this account Drivers License No. Method of Payment Insurance Cash Credit Card Purpose of Call Other Family Members in this Practice Whom may we thank for this referral Patient/parent Social Security No. Spouse/Parent Social Security No. Someone to notify in case of emergency not living with you RELEASE: I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any Information concerning my (or my child's) health care, advice and treatment to another dentist I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carder or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in pad by my dental care payor. I attest to the accuracy of the information on this page. PATIENTS OR GUARDIAN'S SIGNATURE Form No. TI1OR REGISTRATION
6 welcome 1. Purpose of initial visit 2. Are you aware of a problem? Patient's Name First PATIENT NUMBER 2001 Wisconsin Dental Association (800) Last Date of Birth COMMENTS 3. How long since your last dental visit? 4. What was done at that time? 5. Previous dentist's name Address: Tel. 6. When was the last time your teeth were cleaned? CLICK THE APPROPRIATE ANSWER. IF YOU DON'T KW THE CORRECT ANSWER, PLEASE WRITE ''DON'T KW ON THE LINE AFTER THE QUESTION. 7. Have you made regular visits? How often: 8. Were dental x-rays taken? 9. Have you lost any teeth or have any teeth been removed? Why? 10. Have they been replaced? 11. How have they been replaced? a. Fixed bridge Age b. Removable bridge Age If yes, explain 13. Would you like to know about permanent replacements? 14. Have you ever had any problems or complications with previous dental treatment? If yes, explain: 15. Do you clench or grind your teeth? 16. Does your jaw click or pop? 17. Have you experienced any pain or soreness in the muscles or your face or around your ear? 18. Do you have frequent headaches, neckaches or shoulder aches? 19. Does food get caught in your teeth? c. Denture Age 12. Are you unhappy with the replacement? 20. Are any of your teeth sensitive to: Hot? Cold? Sweets? Pressure? 21. Do your gums bleed or hurt? When? 22. How often do you brush your teeth? When? 23. Do you use dental floss? How often? 24. Are any of your teeth loose, tipped, shifted or chipped? 25. Are you unhappy with the appearance of your teeth? 26. How do you feel about your teeth in general? 27. Do you feel your breath is offensive at times? 28. Have you ever had gum treatment or surgery? What? Where? When? 29. Have you had any orthodontic work? 30. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike? 31. Do you have any questions or concerns? I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT'S / GUARDIAN'S SIGNATURE DENTIST'S SIGNATURE ANEST. MED.ALERT Fonn No. T15ODH DENTAL HISTORY
7 welcome Patient's Name Date PATIENT NUMBER Last CIRCLE THE APPROPRIATE ANSWER, IF YOU DON'T KW THE CORRECT ANSWER PLEASE WRITE "DON'T KW ON THE LINE AFTER THE QUESTION 1. Physician's Name Address City State Zip Tel 2. Are you under a physician's care? Since when Why 3. When was your last complete physical exam? 4. Are you taking any medication or substances? (if yes, please list medications in comments section or on the back of this form.) 5. Do you routinely take health related substances?- 6. Are you allergic to any medications or substances? (please list) 7. Do you have any other allergies or hives? 8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications? 9. Are you sensitive to any metals or latex? 10. Are you pregnant or suspect you may be? 11. Do you use any birth control medications? 12. Have you ever been treated for or been told you might have heart disease? 13. Do you have a pacemaker or an artificial heart valve implant? 14. Have you ever had rheumatic fever? 15. Are you aware of any heart murmurs? 16. Do you have high or low blood pressure? (please circle) 17. Have you ever had a serious illness or major surgery? If so, explain 18. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition? 19. Do you have inflammatory diseases, such as arthritis or rheumatism? 20. Do you have any artificial joints/prosthesis? 21. Do you have any blood disorders, such as anemia, leukemia, etc? 22. Have you ever bled excessively after being cut or injured? 23. Do you have any stomach problems? 24. Do you have any kidney problems? 25. Do you have any liver problems? 26. Are you diabetic? 27. Do you have fainting or dizzy spells? 28. Do you have asthma? 29. Do you have epilepsy or seizure disorders? 30. Do you or have you had venereal disease? 31. Have you tested HIV positive? 32. Do you have AIDS? 33. Have you had or do you test positive for hepatitis? 34. Do you or have you had T.B.? 35. Do you smoke, chew, use snuff or any other forms of tobacco? 36. Do you consume alcoholic beverages? 37. Do you habitually use controlled substances? 38. Have you had psychiatric treatment? 39. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products? 40. Do you have any disease condition, or problem not listed? If so, explain 41. Is there anything else we should know about your health that we have not covered in this form? First 2001 Wisconsin Dental Association (800) COMMENTS of Birth 42. Would you like to speak to the Doctor privately about any problem? I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT'S / GUARDIAN'S SIGNATURE DENTIST'S SIGNATURE ANEST. Fonn No. T14OMH MEDICAL HISTORY MED.ALERT
8 The Winning Smiles Dental Offices 2002 Wisconsin Dental Association (800) SECTION A: The Patient. Name: Address: Telephone: Patient Number: Social Security Number: SECTION B: Acknowledgement of Receipt of Privacy Practices Notice. I Privacy Practices from the above-named practice., acknowledge that I have received a Notice of Signature: Date: If a personal representative signs this authorization on behalf of the individual, complete the following: Personal Representative's Name: Relationship to Individual: SECTION C: Good Faith Effort to Obtain Acknowledgement of Receipt. Describe your good faith effort to obtain the individual's signature on this form: Describe the reason why the individual would not sign this form: SIGNATURE. I attest that the above information is correct. Signature: Date: Print name: Include this acknowledgement of receipt in the individual's records. ACKWLEDGEMENT OF RECEIPT OF From No. T303HA PRIVACY PRACTICES TICE Title: Copyright Michael Best & Friedrich, LLC
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Shelly K. Clark, DDS Dentistry For Children
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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,
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
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
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
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
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
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. 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
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
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
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
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
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,
Financial Information Person responsible for child s account Does the patient have dental insurance? Yes. No
NEW PATIENT INFORMATION A LEGAL GUARDIAN FOR THE CHILD MUST COMPLETE THIS FORM. By completing this form thoroughly, you are assisting us to provide the most friendly, safe and efficient care for your child.
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!
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
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
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,
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
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL
School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline, Dorchester and Talbot County Public School system, your child has access to the
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
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:
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
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
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
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
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.,
Welcome to Metropolitan Dental Care
Welcome to Metropolitan Dental Care Personal Information Date First Name Last Name Middle Initial Preferred Name Address Home Phone Work Phone Cell Phone!Male!Female!Minor!Single!Married!Domestic Partner
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Physician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
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
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
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
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:
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: