entat Ins' Referred by: Patient Personal Information Title Last, First Address Birth Date Marital Status Home # Cell # Age M/F Work # DL # SSN
|
|
- Milton Nicholson
- 8 years ago
- Views:
Transcription
1 Referred by: Patient Personal Information Title Last, First Address City, State Zip Birth Marital Status Home # Cell # entat Ins' Age M/F Work # DL # SSN Person responsible/guarantor for paying bills Title Birth Last, First Marital Status Address Home # Cell # City, State Zip Age M/F Work # DL # SSN Do you have Primary Dental Insurance Yes/No Secondary Dental Insurance Yes/No Group #/Name Insurance Name Employer Name Subscriber Last, First Subscriber Address City, State, Zip Relationship to Patient Subscriber ID Birth Patient Medical Information Allergic To Ch eck, if applicable 10 r_i E No known allergies No Known issues t_j Aspirin AIDS/HIV infection Barbiturates/Sleeping Pills Alcohol/Drug Abuse Codeine Anemia/Leukemia Erythromycin Anorexia/Bulimia Iodine Arthritis Latex Rubber Asthma/Hay Fever Local Anesthetics Blood Clotting Issues Metals Blood Transfusion Cil Group #/Name Insurance Name Employer Name Subscriber Last, First Subscriber Address City, State, Zip Relationship to Patient Subscriber ID Fainting Spells/Seizures Fever Blisters/Herpes Frequent Headaches Frequent Dry Mouth Gall Bladder Trouble Heart Attack/Stroke Heart Disease/Angina Premedicate STDs E.] Sinus Trouble Stomach Ulcers Thyroid Problems Tuberculosis Birth Heart Murmur Hepatitis/Jaundice High Blood Pressure ED Unusual Weight Loss Urinate Frequently No Ephephrine Bronchitis Hives/Skin Rash Shortness of Breath Penicillin Cancer/Tumor Joint Replacement on what date: Prior Hepatitis Cardiac Pacemaker Kidney/Bladder Trouble Sulfa Drugs Chest Pain Liver Disease Rheumatic Heart Disease Other Narcotics Color Blindness Mental Health Problems Contact Lenses Mitral Valve Prolapse Damaged Heart Value Persistent Diarrhea
2 Dental Questionnaire Name of Previous Dentist Phone Number of your last cleaning of your last exam of your last full series x-rays of last cavity detection (bitewing) x-rays Do your gums bleed while brushing or flossing? Are your teeth sensitive to hot, cold or sweets? Do you get frequent fever blisters, mouth ulcers or sores on your lips or your mouth? Have you ever had burning of the tongue or cracking of the corners of your mouth? Do you chew/smoke tobacco in any form? Have you had any head, neck or jaw injuries? Do you notice popping, clicking or soreness of the jaws or points just in front of the ears? Do you clench or grind your teeth? Have you ever had orthodontic treatment? If yes, date of placement Do you wear dentures or partials? If yes, date of placement Are you happy with your dentures? Are you having any specific problems with your teeth, gums or mouth at this time? Are you happy with your smile? Do you have problems with teeth/fillings breaking? Do you regularly use dental floss? Have you ever been told you have Pyorrhea? Do you have difficultly in opening your mouth widely? Do you have an unpleasant taste or odor in your teeth/mouth? Does food catch between your teeth? Do you want to learn to control dental disease and retain your teeth? E n CONSENT The undersigned hereby authorizes Dr Moore (hereafter known as Doctor) to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with Name of Patient: And the undersigned further authorizes and consents that the Doctor choose and employ such assistance as deemed fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that the responsibility for payment of dental services provided in this office for myself is mine, and that payment is due and payable at the time services are rendered. Patient Witness
3 Medical Questionnaire Family Physician Phone # Are you currently under care of a Physician? If yes, what is the condition being treated? Have you had any serious illness, operation or been hospitalized with the last 5 years? If yes, what illness or problem? Are you currently taking any medications? If Yes, which? Have you taken bisphosphonates? (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast) Have you ever taken the diet control drug Fen-Phen? Do you use alcoholic beverages? Do you smoke? Women Only Are you pregnant? If yes, what is your due date? Are you currently nursing? Do you have menstrual period problems? Are you on hormone replacement therapy? Are you on birth control pills/fertility drugs? Additional Comments Any disease, condition or problem not listed? Senior Citizens Are you in a wheel chair? By signing below, I certify that all of the above information is true to the best of my knowledge. Patient/Guardian Signature Witness
4 R aj) \S4- Dentat Insr Star Dental Institute 2620 TENDERFOOT HILL ST, SUITE 210 COLORADO SPRINGS, CO ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse To Sign This Acknowledgement office's Notice of Privacy Practices., have reviewed a copy of this Please Print Name Signature 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 Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify) 1
5 \-S4- dental Star Dental Institute 2620 TENDERFOOT HILL ST, SUITE 210 COLORADO SPRINGS, CO FINANCIAL POLICY FOR OUR PATIENTS Great dental treatment is vital to the quality of your life and we are sensitive to your concerns about paying for it. We will gladly discuss the payment options we have available before beginning any treatment. Please review the following payment opportunities. DENTAL INSURANCE: Our office will work with you to maximize your available benefits and diligently follow up on claims to secure payment. In return we ask that you pay your deductibles and copays on the day treatment is rendered. Most insurance plans do not cover 100% of our fees. We will do our best to estimate your patient portion but please understand these estimations cannot be guaranteed. Your insurance is an agreement between you and your insurance company and you are ultimately responsible for all charges. We will do everything possible to help you receive your benefits, but if your insurance does not pay their portion within 60 days of your treatment, you are responsible for full payment of the balance at that time. Deposits: An appointment deposit is required at the time of scheduling treatment. PAYMENT OPTIONS: 1. We offer a 5% discount for treatment that is paid in full in advance of treatment. A 3% discount is offered for treatment that is paid in full in advance when paid by credit card. A 10 % down payment is made by cash check or credit card at the time the appointment is scheduled. 2. We accept cash, checks and VISA, MasterCard, Discover and American Express. 3. We offer outside financing through Care Credit and Arch Advantage. Ask us for the latest details on their low and no interest rates options and number of months to pay options. 4. We offer an appointment based plan that includes a down payment and two equal payments made at the time of appointments. 5. We offer a 10% Senior Discount to patients 60 years or older who pay at the time of service. I understand the Financial Policies of Star Dental Institute. Signature of Responsible Party Printed Name
6 5?"91- Den tat Ins Medicaid Consent - Authorization for Dental Treatment I hereby authorize Dr. Gary Moore DDS and his associates to provide dental services, prescribe, dispense and/or administer any drugs, medicaments, antibiotics, and local anesthetics that he or his associates deem, in their professional judgment, necessary or appropriate in my care. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions (tooth removal). The most common risks can include, but are not limited to: Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest. I realize that it is mandatory that I follow any instructions given by the dentist and/or his/her associates and take any medication as directed. I understand that NO GUARANTEES OR WARRANTIES as to the results of treatment can be made with any dental treatment given to me. Alternative treatment options, including no treatment, have been discussed and understood. A full explanation of all complications is available to me upon request from the dentist. I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with family member. I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or in paper form to my insurance carrier or any related entities that require such information to be submitted. I acknowledge that I have reviewed a copy of this office's Privacy Policies. I agree to disclose to the dentist names of any individuals with whom I authorize the dentist to discuss my dental care. I authorize the doctor, and/or such associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and for administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation. I understand that as part of the dental treatment, including preventative procedures such as cleanings and basic dentistry, including fillings of all types,
7 teeth may remain sensitive or even quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions. All claims and disputes arising under this Agreement that cannot be resolved by the parties must first be submitted to a mediator in an attempt to resolve the dispute outside of litigation. Any such mediation shall begin within seven days from the request for mediation by either party. The mediation must be completed within ten days thereafter. The plaintiff will bear the cost of mediation. If the parties do not submit to this mediation in good faith, as determined by the mediator, the parties may not proceed with any other remedies under this Agreement. I am aware the doctor does use amalgam (mercury) fillings to restore teeth. I understand my insurance may or may not cover composite (white) fillings; I am responsible to pay the difference if I choose to have more expensive white fillings or crowns. After lengthy appointments, jaw muscles may also be sore or tender. Holding one's mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required. I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past,. I understand that taking the any drugs prescribed for the prevention of osteoporosis, heart or systemic problems, such as Fosamax, Boniva, Actonel, and blood thinners such as aspirin may result in complications of non-healing or very slow healing of the jaw bones following oral surgery or tooth extractions. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions. I understand that I am solely responsible for the full payment of services received from this office on ANY and ALL procedures that are uncovered and/or denied by MEDICAID. Patient Name (please print): Patient Signature: Witness:
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
More informationNew 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
More informationGalerie 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
More informationStanwood 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,
More informationPatient 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
More informationPATIENT 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
More informationThank 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
More informationPatient 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:
More informationAlldent 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
More informationSUMMERVILLE 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:
More informationPATIENT 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
More informationWelcome 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
More informationGuardian/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.
More informationNearest 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
More informationHow 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
More information! 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
More informationDate. 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
More informationPatient 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
More informationSHREVEPORT-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
More informationRIVERTOWN 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
More informationWelcome 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
More informationWelcome 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
More informationPatient 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
More informationADULT 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?
More informationEmergency 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
More informationPatient 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
More informationCONSENT 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
More informationWelcome 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
More informationGeneral 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.
More informationChad 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:
More informationTrinity 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
More informationWhat 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
More informationName: 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
More informationPatient 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
More informationOtis 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):
More informationwelcome 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
More informationMICHAEL 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
More informationWELCOME 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.
More informationNEW 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,
More informationWelcome 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
More informationBrian 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
More informationTitle 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
More informationWelcome 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
More informationOffice 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
More informationWelcome 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
More informationElmwood 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
More informationMobile Dental Care QUALITY ON-SITE DENTISTRY SINCE 1982
CONCERNING MEDICAID For Patient: The process for Medicaid to approve the necessary dental treatment and to also fund for that treatment is a slow and confusing procedure. Essentially, Medicaid will make
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationPatient 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.
More informationDouglas 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
More informationAcknowledgement 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
More informationIn case of EMERGENCY, contact: Relationship to Patient: Home Tel. ( ) Work Tel.( ) Mobile Phone: ( )
PATIENT INFORMATION West Coast Oral Surgery (Mr., Mrs., Ms., Dr.) First Name: M.I. Last Name: Sex: ( )Male ( )Female Date of Birth: Age: Social Security Number: Street: Apt./Suite# City: State: Zip: Home
More informationPATIENT 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:
More informationINSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS
INSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS Please answer all questions on the welcome page. Please fill in all of your information on the ABOUT YOU page including where you live, the phone number
More informationWelcome. 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
More informationMEDICAL 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
More informationDate 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
More informationPatient 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
More informationWelcome to Associates For Dental Care, LLC!
Welcome to Associates For Dental Care, LLC! REGISTRATION FORM Section I Patient Information Name: I Prefer to be called: Address: City: State: Zip Phone ( ) Work Phone ( ) Cell Phone ( ) The best time
More informationBOYER CHIROPRACTIC INC
Patient Name: Birthdate: Sex: M / F Address: City: State: Zip: Telephone: Social Security #: Driver Lic. #: Occupation: Employer: Work Phone: Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
More informationWelcome 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
More informationPATIENT 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:
More informationWelcome 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
More informationRALPH 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
More informationThe 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
More informationNEW 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
More informationFinancial 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.
More informationORTHODONTIC TREATMENT
ORTHODONTIC TREATMENT Informed Consent for the Orthodontic Patient As a general rule, positive orthodontic results can be achieved by informed and cooperative patients. Thus, the following information
More information*WELCOME TO OUR OFFICE*
*WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME
More informationPatient 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:
More informationAloha Medical Mission
Aloha Medical Mission Medical Alert: Condition: Premedication: Allergies: : HEALTH HISTORY FORM Name: Home Phone: ( ) Business Phone: ( ) LAST FIRST Address: City: State: Zip Code: Marital Status: Single
More informationPayment 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
More informationCarter Physiotherapy, PLLC. Patient Contact Information
Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip Code DOB Gender Marital Status Occupation Home Phone Work Cell Other Fax Email Employer Work Address
More informationPatient 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:
More informationOur 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
More informationPATIENT 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:
More informationHorizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
More informationACKNOWLEDGEMENT 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. Please Print Name Signature
More informationMedical Billing - Informs, Guidance and Procedure Planning
PATIENT NAME: BIRTH DATE: DATE: LAST FIRST DENTAL HISTORY 1. Reason for Visit / Main Concern? Check-Up Cleaning Toothache Other 2. Are there other conditions of which we should be aware? YES NO If yes,
More informationAre 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
More informationWestoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
More informationPhysician 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
More informationPart 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
More informationSingle 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
More informationOrthodontics 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
More informationHow To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
More informationScheduling. 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
More informationLake 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
More informationMother 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.,
More informationNondiscrimination 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
More informationPATIENT 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,
More informationMedical 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
More information375 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
More informationShelly K. Clark, DDS Dentistry For Children
Shelly K. Clark, DDS Dentistry For Children Patient Last Name, First Name Middle Date of Birth Goes by: Whom may we thank for referring you to our office? Age: Male / Female Who is accompanying the child
More informationPATIENT 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
More informationAirport 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,
More informationWe 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!
More informationSedadent Anesthesia Services Jarom Heaton D.D.S., M.S. Instructions:
Sedadent Anesthesia Services Jarom Heaton D.D.S., M.S. Instructions: To Dental Staff: Please fill out the Anesthesia Patient Information form and fax to Dr. Heaton s office @ 512-246-3678 or drop in the
More informationkarrdds.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
More informationInsurance (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:
More information