For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure.
|
|
|
- Dorthy Walton
- 7 years ago
- Views:
Transcription
1 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, check, Visa, Mastercard or debit cards. We offer a 5% discount if you pay in full by cash or check at the time of service. If you wish to pay in full at the time of service with a credit card, we will offer a 3% discount. Charges not paid at the time of service are due within 30 days. INSURANCE As a courtesy, we will bill your insurance company for you if provided with all the proper billing information. All accounts are due within 60 days, regardless of insurance involvement. A 1.5% monthly finance charge will be assessed on all accounts past 60 days. You will receive a monthly statement regarding your account activity. estimates We can provide a treatment plan with an estimate of total fees after the initial visit. This treatment plan will also include, in writing, a breakdown of our fees, the estimated insurance coverage, and your portion that will be due at each visit. We would like to emphasize that these are estimates. Should additional unforeseen problems or complications arise as treatment progresses, you will be kept informed. PAYMENT OPTIONS Please feel free to discuss payment options with our staff. We offer several plans that will help you with financial planning. CANCELLATION POLICY There may be a $50 fee for an appointment that is cancelled with less than 48 hours notice. 600 Broadway Suite 330 Seattle, WA dentalcareseattle.com
2 WELCOME TO OUR PRACTICE 600 Broadway Suite 330 Seattle, WA Office hours Monday 8 a.m. to 5 p.m. Tuesday 7 a.m. to 5 p.m. Wednesday 8 a.m. to 5 p.m. Thursday 8 a.m. to 5 p.m. Friday 7 a.m. to 3 p.m. Parking Parking is available in our building, with access at the bottom of Cherry Street on the North side. Street parking is also available on two hour parking meters on each street surrounding our location. Appointments We know there are times when you cannot keep your appointment. If this happens, we require 48 hours notice so we may utilize this time for another patient. WEB PAGE Please check our web page dentalcareseattle.com for answers to most of your questions. In addition, you can print out the registration and health history forms from our web site and bring them with you to your first appointment. Please call us for any further questions. BROADWAY E UNION ST BOREN AVE MADISON ST Seattle University E CHERRY ST (James turns into Cherry) CHERRY ST JAMES ST 12TH AVE W N S E MADISON ST Cherry street deadends, with parking under our building. 600 Broadway Suite 330 Seattle, WA dentalcareseattle.com E YESLER WAY CHERRY ST S JACKSON ST AMES ST CHERRY ST JAMES ST BROADWAY 2TH AVE
3 ACKNOWLEDGEMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICES I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dental Care Seattle. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Dental Care Seattle reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (PLEASE SPECIFY) YES NO Name of Patient or Personal Representative Signature of Patient or Personal Representative Date Description of Personal Representative s Authority
4 STATEMENT OF PRIVACY PRACTICES Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights. PROTECTING YOUR PERSONAL HEALTH INFORMATION We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone even family members without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released. COLLECTING PROTECTED HEALTH INFORMATION We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes. We may use and/or disclose your health information to communicate reminders about your appointments including voic , answering machines, and postcards. PATIENT RIGHTS You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. We thank you for being a patient in our practice. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information. 600 Broadway Suite 330 Seattle, WA dentalcareseattle.com
5 PATIENT HEALTH HISTORY Name Employer/Occupation Physician/Location Are you allergic to: Penicillin? Codeine? Latex? Other allergies? Current medications? (Women) Are you pregnant? Do you have a history of any of the following? Please check: Artificial heart valve Heart surgery Heart disease Heart murmur Pacemaker Diabetes Radiation treatment HIV Prolonged bleeding Other? Cancer/tumor Bis-phosphonates Artificial joint Diet drugs Anemia Hepatitis/liver disease Sinus trouble Surgery Sleep disorder Epilepsy Glaucoma Asthma High blood pressure Ulcers T.B. or lung disease Arthritis Tobacco use Thyroid disorder Comments: OVER
6 600 Broadway Suite 330 Seattle, WA PATIENT REGISTRATION Date: preferred name: NAME SEX CHILD SINGLE M F MARRIED OTHER SPOUSE S NAME/PARENT S NAME (IF MINOR) YOUR SOC. SEC. # BIRTH DATE HOME PHONE ADDRESS CITY ZIP CELL PHONE WHO REFERRED YOU? EMPLOYER OCCUPATION WORK PHONE YOUR ADDRESS EMERGENCY CONTACT (OTHER THAN SPOUSE) Insurance Information PRIMARY DENTAL INSURANCE GROUP #/EMPLOYER NAME OF SUBSCRIBER (OTHER THAN SELF) BIRTH DATE INS. ID # OR SEC. SEC. # SECONDARY DENTAL INSURANCE GROUP #/EMPLOYER NAME OF SUBSCRIBER (OTHER THAN SELF) BIRTH DATE INS. ID # OR SEC. SEC. # MY PRIMARY PREFERENCE FOR COMMUNICATION: TEXT PHONE I have read Dental Care Seattle s financial policy. (initials) I am financially responsible for my own account. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. If insurance coverage exists, I authorize payment to go directly to my dentist. SIGNATURE DATE OVER
7 PATIENT HEALTH HISTORY Name Employer/Occupation Physician/Location Are you allergic to: Penicillin? Codeine? Latex? Other allergies? Current medications? (Women) Are you pregnant? Do you have a history of any of the following? Please check: Artificial heart valve Heart surgery Heart disease Heart murmur Pacemaker Diabetes Radiation treatment HIV Prolonged bleeding Other? Cancer/tumor Bis-phosphonates Artificial joint Diet drugs Anemia Hepatitis/liver disease Sinus trouble Surgery Sleep disorder Epilepsy Glaucoma Asthma High blood pressure Ulcers T.B. or lung disease Arthritis Tobacco use Thyroid disorder Comments: OVER
STATEMENT OF PRIVACY PRACTICES
STATEMENT OF PRIVACY PRACTICES We, at Seattle Smile Works, are dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee
! 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
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:
Welcome to Seattle Smiles Dental
Welcome to Seattle Smiles Dental The Puget Sound Plaza 1325 4 TH Avenue, Suite 1230 Seattle, Washington 98101 TEL: 206.624.1773 FAX: 206.624.2268 info@seattlesmilesdental.com MISSION Our mission is to
Payment Is Expected At Time Of Each Visit Please Check Method of Payment
Rachel Mahoney, DMD 21727 76th Ave West Suite G Edmonds, WA 98026 Office (425) 967-7272 www.mahoneyfamilydentistry.com Fax: (425) 967-7262 ank you for trusting your child with our o ce. In order to serve
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,
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
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
Nearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
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,
How did you hear about our office?
PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Email Employer
MICHAEL D BROOKS, DMD, MS, PLLC MICHAEL J BOWMAN, DDS, MS, PLLC PATIENT INFORMATION RECORD DENTAL INSURANCE
PATIENT INFORMATION RECORD NAME DATE DATE OF BIRTH SEX SOCIAL SECURITY HOME ADDRESS HOME PH EMAIL CITY STATE ZIP EMPLOYER OTHER PH DENTAL INSURANCE PRIMARY SUBSCRIBER NAME SOCIAL SECURITY # DATE OF BIRTH
Date Home Phone ( ) Address. City State Zip. Patient Employer/ School Occupation. Employer/School Address Employer/School Phone ( )
Welcome to Dr. Christine Theroux Family and Cosmetic Dentistry! PATIENT INFORMATION Date Home Phone ( ) Name Last Name First Name Middle Initial SS/HIC/Patient ID # E mail Address City State Zip Sex M
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address City, State, Zip: Home Phone: Work Phone: Cell Phone: Birth Date: Age: Sex: Male Female Soc. Sec. #: Occupation: Employer: Marital Status:
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
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
Welcome to Dr. Moritis Dental Office
Welcome to Dr. Moritis Dental Office Patient Information First Last M.I. Address City State Zip Home Phone Work Phone Cell Phone Email Social Security # Birth date Gender M F Marital Status Single Married
What is the best way to contact you?
IDENTIFICATION PATIENT REGISTRATION Today's Date PLEASE PRINT CLEARLY AND FILL IN ALL THE SPACES BELOW Patient Name (Last, First, Middle Initial): Date of Birth Social Security # Mailing Address City State
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
Elmwood Dental Center Patient Information Form 1128 Clearview Pkwy Metairie, LA 70001 PHONE: (504) 733-1135
Elmwood Dental Center Patient Information Form 1128 Clearview Pkwy Metairie, LA 70001 PHONE: (504) 733-1135 Welcome! Please print this form, fill it out, and bring it with you when you arrive for your
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:
ADULT DENTAL HISTORY I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE. 1. Purpose of initial visit?
ADULT DENTAL HISTORY 1. Purpose of initial visit? Doctor s Notes 2. Are you aware of any dental problems?... If yes, please explain 3. How long since your last dental visit? 4. What was done at that time?
Patient Information. 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
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
Brian H. Jamieson D.D.S. Esthetic Family Dentistry 1533 Grove Street Marysville, WA 98270 (360) 659-3200
Esthetic Family Dentistry 1533 Grove Street Marysville, WA 98270 (360) 659-3200 Welcome to Our Office - Tell Us About Yourself Name Last First MI Title Preferred Name: p Male p Female Address: City State
Address City State Zip. Cell Phone# Home# Work# Date of Birth / / Age Social Security# - - Sex: Male / Female. Driver s License# State
3191 Maguire Blvd, Suite #251 Orlando, Florida 32803 407-894-1451 phone 407-894-5656 fax PATIENT INFORMATION Legal Name of Patient Nickname Address City State Zip Cell Phone# Home# Work# Date of Birth
CONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
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
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.
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
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
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
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
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
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
Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is
Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is our main objective. You can rest assured in knowing that Dr. Tomack and Dr. Behrens have your best interest
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
How 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
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
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
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
Welcome tokentlands Dental Care
Patient Information Welcome tokentlands Dental Care Last Name: First Name: MI: Birthdate: Male Female Marital Status: Single Married Other SSN: Address: Apt. No. City: State: Zip: Home Phone: ( ) Work
Patient Information. Referral Information Name of person or Doctor referring you to our practice:
Patient Information Patient First Name: Middle Initial: Last Name: Preferred Name: Address: City/State: Zip: Home Phone: Work Phone: Cell Phone: Sex: Male Female Marital Status: Married Single Divorced
Patient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
Name: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
PATIENT INFORMATION Thank you for choosing us as your dental care provider. We look forward to caring for you! Patient Information: Patient Name (First Middle Initial Last): DOB: / / SS#: / / Driver s
RIVERTOWN DENTAL CENTER
PATIENT INFORMATION RIVERTOWN DENTAL CENTER DATE PATIENT NAME DATE OF BIRTH S.S.N AGE SEX M F MARRIED SINGLE SEPARATED DIVORCED WIDOWED SPOUSE S NAME ADDRESS CITY ZIP PHONE ( ) CELL PHONE ( ) EMAIL DENTAL
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
Patient Information. Middle Name Last Name Preferred Name è. Home Address City State Zip è
. Patient Information Mr. Mrs. Ms. Dr. Male Female Single Married Divorced Widowed First Name Middle Name Last Name Preferred Name Home Address City State Zip Social Security Number Drivers License Number
SHREVEPORT-BOSSIER FAMILY DENTAL CARE
SHREVEPORT-BOSSIER FAMILY DENTAL CARE Patient's Name: Patient's Birthdate: (FIRST, MIDDLE, LAST) Patient's SSN #: Patient's Email Address: _ Patient's Phone #: Home:_ Cell: Work: Patient's Address: Patient's
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print
Office Hours: Monday - Thursday 8:00 A.M. 5:00 P.M. New Patient Exams & Cleanings:
We want to provide you with the best dental care possible in an efficient and timely manner. Please take a moment to review our office policies to help us achieve our goals in serving you. If you are a
PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400
PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400 Patient Information as of (todays date). Please print legibly and
Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D.
Patient Information Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D. Patient Name Date of Birth Age Address Marital Status Sex Address Home ( ) City State Zip Cell ( ) Employer Work
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 AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
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
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!
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
The Dermatology & Laser Group of Irvine, A.M.C. 16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115
16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115 (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Email: Mr. Ms.
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250. Referring Doctor: PLEASE PRINT CLEARLY Email Address:
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250 Date: Referring Doctor: PLEASE PRINT CLEARLY First Name: Last Name: Height: Address: City, St., Zip:_ Email Address: _
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
North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,
welcome REGISTRATION SummerHills Dental DENTAL INSURANCE 1ST COVERAGE DENTAL INSURANCE 2ND COVERAGE Age Date Patient s Name Date of Birth Male Female
welcome Age Date Patient s Name Date of Birth Male Female Last First If Child: Parent s Name How do you wish to be addressed Single Married Separated Divorced Widowed Minor Residence Street City State
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
Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist
GFP GARDENS FAMILY PRACTICE Phone (561) 627-7433 Fax (561) 775-1055 Welcome To Gardens Family Practice! We are happy to have you join our family and would like to give you some general information regarding
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
Welcome to our Practice! Thank you for choosing our office for your dental care!
Welcome to our Practice! Thank you for choosing our office for your dental care! We are dedicated to providing you and your family with the highest quality of care, using state of the art treatment in
PATIENT REGISTRATION FORM
: 610 Professional Dr., Suite 250 Gaithersburg, MD 20879 www.greatsmilesdentalcare.com PATIENT REGISTRATION FORM Great Smiles Dental Care takes your oral health very seriously. To help us meet all your
New York Ophthalmology, P.C.
New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision
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
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
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:
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949 Thank you for choosing Lanier Chiropractic and Rehabilitation! It is our desire
Our Commitment to You
For your convenience you may use your keyboard and mouse to complete this form. Our goal is to help you achieve and maintain excellent dental health. The better we communicate, the better we can care for
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
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
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:
Galerie Dental Care. Patient Information. Emergency Contact Relationship: Phone:
Galerie Dental Care Patient Information Date: Patient Name: Last First Middle Initial (Preferred Name) Gender: Birth Date: Marital/Family Status Address: Street Apartment # City Province Postal Code Phone
Patient Registration Form
Patient Registration Form Name (Last, First, Middle) SSN# Age Marital Status Maiden Name Address Patient Home Phone Patient Business Phone Patient Cell Phone Patient E-mail Patient Occupation Business
Employment Status Full Time Part Time Retired Not Employed Work Address: City: State: Zip:
PATIENT INFORMATION First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Email: DOB: Male Female S.S. #: - - Home Phone: ( ) Mobile Phone: ( ) Work Phone: ( ) Employer: Occupation:
PATIENT REGISTRATION. First Name: _ Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: _. Address: _ Address 2: _
TIME 145 PM DATE 10/13/2008 10: Chart 10: PATIENT REGISTRATION First Name: Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: o Responsible Party Responsible Party (Wsomeone other than
How To Contact A Doctor From A Doctor'S Office
Anthony S. Lombardi, MD, FACS Nilla Defazio, PA C Jessica Henderson, PA C PATIENT INFORMATION Date Patients Last Name First Name M.I. Suffix(i.e,Jr.,Sr.) Street Address City State Zip Code ( ) ( ) M S
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C
275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:
MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information
MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S.
New Patient Information
New Patient Information LAST FIRST NAME NAME M.I. DATE OF SOC. MARITAL BIRTH SEC. SEX STATUS PRIMARY ADDRESS PHONE CELL CITY STATE ZIP PHONE WORK EMPLOYER PHONE REFERRING/ YOUR PRIMARY PHYSICIAN E-MAIL
EZ REHAB SOLUTIONS: Patient Intake Information
EZ REHAB SOLUTIONS: Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez
Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez New patient history form Patient name DOB Allergies to Medicines: Current Medications Name Dose Times/day taken Social History Married/single/widowed/divorced
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
Horizon 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)
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:
Are you in good health Yes No Chronic fatigure/night sweats. Yes No
Healthy Smiles Health History Patient's Name Are you in good health Yes No Chronic fatigure/night sweats. Yes No Has there been any change in your health Do you have implants? within the past year.. Yes
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
NEW PATIENT WELCOME PACKET PATIENT INFORMATION
6511 Campbell Boulevard Lockport, New York 14094 Phone: (716) 625-4129 Fax: (716) 625-4491 www.keepsmiling.us NEW PATIENT WELCOME PACKET Welcome and thank you for selecting Marian C. Pilecki, DDS, and