We look forward to meeting you. Sincerely, Bradley A. Blair, DDS and Staff
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1 Bradley A. Blair, DDS Comprehensive Dentistry Esthetic, Restorative & Preventive 1101 Norton Rd, Galloway, Ohio Welcome to our office! We appreciate the confidence and trust that you have placed in us and look forward to meeting you personally and professionally. Our philosophy of care governs everything we do for you. It consists of the following key elements: We are truly caring about our patients and want you to feel very comfortable with our entire staff. We recognize that each patient is an individual and our goal is to help you retain your teeth in comfort, function and esthetics for a lifetime. We work with only one patient at a time, and do not double book. The time that you reserve with us is yours and yours alone. We strive to be thorough in everything we do, taking the time to be the best we can be. We are esthetics oriented, helping you look your best, while maintaining optimum comfort, function and health. At your first visit, we will take the time to get to know you (and you, us) and discuss your dental needs and desires. We will perform a comprehensive dental evaluation and gather information to make a customized plan for you. This will take approximately 90 minutes. Enclosed you will find our new patient information form. Please fill this out and bring it with you to your first appointment along a list of any medications that you take. We look forward to meeting you. Sincerely, Bradley A. Blair, DDS and Staff P.S. Please visit our website at to learn more about us!
2 BRADLEY A. BLAIR, D.D.S. GENERAL DENTISTRY 1101 NORTON ROAD GALLOWAY, OHIO FAX Welcome to our office. We appreciate your selection of this office to serve your dental health needs. Our goal is to provide the very best possible dental care for our patients so that each of you may maintain optimum dental health throughout your lifetime. Please provide us with the following information so that we may get to know you better. Date Name Social Security Number Home Address City Zip Address Home Telephone Work Cell Occupation Company Name Company Address By what name do you wish to be called in our office? Birthday Marital Status Name of Spouse Whom may we thank for referring you to our office? Are other family members patients here? Who is your medical doctor? What in particular brings you to our office? Method of payment: Payment at time of visit Mastercard or Visa Dental Insurance. Name of Insurance Company Name of Insured Birthdate of Insured SSN Company Name & Address Do you have Dental Insurance Coverage other than your own? Name of Insurance Company Name of Insured Birthdate of Insured SSN Company Name & Address
3 For our patients with dental insurance, please remember that YOU ARE RESPONSIBLE FOR PAYMENT. Remember too that few insurance companies attempt to cover all dental costs. Some pay fixed allowances for certain procedures, others pay a percentage of the charge. It is your responsibility to pay any deductible, co-insurance, or other balance not paid for by your insurance. DENTAL HISTORY Date Name Reason for Appointment Do you desire complete and thorough dental care or treatment of a specific problem only? Have you had regular preventive dental care in the past? When was your last dental appointment? Do you feel that saving your teeth is worth the effort? Are you satisfied with the appearance of your smile? If you could change anything about your smile, what would it be? Do you care if metal fillings show? Have you ever had orthodontic treatment (braces)? Have you ever had any wisdom teeth removed? Do you wear a removable partial or denture? Year made If yes, are you satisfied with it? Have there ever been any injuries to your mouth? Are your gums ever sore or do they bleed? Do you have any loose teeth? Have you ever been told that you have gum disease (pyorrhea)? Do you have any sore or sensitive teeth? Do you ever notice sounds or pain in the jaw joint? Have you ever been told that you have a problem with your bite? Do you clench or grind your teeth?
4 Have you ever had any trouble with previous dental treatment? Do you have any other concerns that we should know about? MEDICAL HISTORY Are you in good health? Are you in the regular care of a physician? If so for what? Have you been in the hospital in the last 2 years? Do you take any medications? Do you use tobacco in any form? How much? Are you allergic to any medications? Have you ever had any excessive bleeding problems? Have you ever had a bad reaction to a medication? (Women) Are you pregnant now or trying? Have you had any of the following: Heart Trouble Asthma Seizures Fainting Venereal Disease Epilepsy Chest Pain Diabetes Hepatitis High Blood Pressure Heart Attack Stroke Heart Murmur Liver Disease Ulcers Cancer Arthritis Jaundice Kidney Trouble Rheumatic Fever AIDS Do you have any other health problems that we should know about? Patient s Signature
5 Drs Eisenman & Blair 1101 Norton Road Galloway, Ohio NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name Relationship to Patient Signature: Date OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: Date: Initials: Reason:
6 Tell Us About You... The better we understand you, the better we can serve you. We don t like to make assumptions or guess about what makes you tick. Please make a mark along each scale below to indicate your opinion or preference. I know a great deal about my dental condition I like to be presented with fewer options I tend to look at the details I prefer long-lasting solutions which may cost more I prefer to talk in technical terms with my dentist My insurance largely determines the extent of my care I prefer to wait until I must act I rely more on self-maintenance I like newer and more modern techniques I favor a treatment-oriented approach to disease I know very little about my dental condition I like to be presented with more options I tend to look at the big picture I prefer more temporary solutions at lower cost I prefer to talk in non-technical terms I largely determine the extent of my care I usually see no reason to delay care I rely more on professional maintenance I prefer tried and true methods I favor a cause-oriented approach to disease In order of importance, I generally consider the following benefits (please rank 1 through 7 or 8): Comfort Appearance Peace of Mind Function Precision Durability Health Other In order of importance I generally weigh the following costs (please rank 1 through 5 or 6): Money Time Personal Effort Physical Discomfort Fear / Anxiety Other ProSynergy Dental Communications Seattle, WA (800)
7 Bradley A. Blair, DDS Comprehensive Dentistry Esthetic, Restorative & Preventive 1101 Norton Rd, Galloway, Ohio Facts About Dental Insurance As an optimal-care dental practice, we strongly believe our patients deserve the best possible dental services we can provide. In an effort to maintain a high quality of care, we would like to share some facts about dental insurance with you. Fact #1: Your dental insurance is based upon a contract between your employer and the insurance company. Should questions arise regarding your dental insurance benefits, it is best for you to contact your employer or the insurance company directly. Fact #2: Dental insurance benefits differ greatly from traditional medical health insurance benefits and can vary quite a bit from plan to plan. When dental insurance plans first appeared in the early 1970's most plans had a yearly maximum of $1000. Today, some 30+ years later, most plans still have an annual maximum of $1000. That the premiums remained the same, allowing for a conservative yearly rate of inflation, your yearly plan maximums should be in excess of $4500 today. Your premiums have increased, but your benefits have not. Therefore, dental insurance was never set-up to cover your services 100%; it is only an aid. Fact #3: You may receive a notification from your insurance company stating that dental fees are "higher than usual and customary." Insurance companies never reveal how they determine "usual, customary and reasonable" (UCR) fees. A recent survey done in the state of Washington found at least eight different UCR fee schedules for one zip code in the Seattle area. The fees are somehow determined by taking "a percentage" of an average fee for a particular procedure in a geographic area. Average has been defined as "the worst of the best" or "the best of the worst." We do not provide average dentistry nor do we charge average fees. Fact #4: Many plans tell their participants that they will be covered "up to 80% or up to 100%," but do not clearly specify plan fee schedule allowances, annual maximums, or limitations. It is more realistic to expect dental insurance to cover 35 to 50 of major services. Remember, the amount a plan pays is determined by how much the employer paid for the plan. You get back only what your employer puts in, less the profits of the insurance company. Fact #5: Many routine dental services are not covered by insurance companies. This does not mean they aren't necessary or appropriate, just not covered. We feel that dental insurance can be a great benefit for many patients and want you to know we will do everything in our power to insure that you get every benefit dollar you are entitled to. However, the treatment we recommend and the fees we charge will always be based on your individual need, not your insurance coverage. The ultimate decision as to what will be done and how fast we proceed will always be made by you. Based on your decision, we will discuss the total cost of treatment and what assistance you can expect from your dental insurance. 'All arrangements are strictly between you and our office. The full responsibility for payment of services rendered will always be with you.
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Jaworski Physical Therapy, Inc. Patient Name: Date: Private Health Insurance Name of Private Health Insurance: ID#: Group#: Cardholder Name: Cardholder Date of Birth: Relationship to Patient: Phone: Address
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
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
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
W E L C O M E Please Tell Us About Your Child **************************************** Bend (541) 312-2490 Redmond (541) 923-8666
W E L C O M E Please Tell Us About Your Child **************************************** Bend (541) 312-2490 Redmond (541) 923-8666 Tell Us About Your Child Today's Date / / Male Female Name Nickname Birth
New/Updated Patient Information
New/Updated Patient Information Please Fill Out Completely: Date: Patient Name: Nickname: First M.I. Last Date of Birth: // Age: SSN: _/_/_ Gender: M F Email: Mailing Address: Marital Status: Single Married
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
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.
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
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:
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,
Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11
PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you
PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:
NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:
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
Part Four: Who is Accompanying the Child Today? Part One: Tell Us About Your Child. Part Five: Referral. Part Six: Person Responsible for Account
Kee Kwak, DDS Grace E. Smart, DDS, MS, PC 2426 Beltline Road Garland, TX 75044 New Patient Health History Form Print this form, complete all information, and bring it with you on your first visit to our
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
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:
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.
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Chad Biggio D.D.S. 8480 Bluebonnet Blvd Ste. E Baton Rouge, LA 70810 (225) 767-4491 PATIENT INFORMATION
Chad Biggio D.D.S. 8480 Bluebonnet Blvd Ste. E Baton Rouge, LA 70810 (225) 767-4491 PATIENT INFORMATION Patient s Name: First Middle Last If Child: Parent or Guardian Name: Relation: Address: Apt #: City:
Welcome to Northborough Family Dental
Date: Patient Information: Welcome to Northborough Family Dental Name D.O.B. SS# Address Apt Town State Zip Marital Status Home Phone Cell# Other Email Employer Work Phone EMERGENCY CONTACT: Name Phone