John B. DeBonis, D.M.D 467 Lincoln Ave, Pittsburgh PA (412)
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- Laurel Charles
- 5 years ago
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1 Hello, Welcome to the office of Dr. John B. DeBonis. Thank you for choosing us for your dental health needs. By choosing us you have selected a practice whose doctor has demonstrated the highest level of clinical excellence that you would want in your dentist. Our office has had the privilege of providing outstanding dental care in the Bellevue area and surrounding communities since I graduated first in the class of 1987 from the University of Pittsburgh School of Dental Medicine. I am passionate about my family, our patients and our community. I enjoy racquet sports, especially paddle tennis and ping pong. This will confirm that you are scheduled for your appointment on at. We ask that you please plan to arrive promptly for your check-in time of, which is 15 minutes before your scheduled appointment. This allows us time to obtain any additional details needed prior to your appointment time. In preparation for your appointment, we ask that you please complete the Welcome Packet included with this letter. This will allow us to maximize your appointment time. There is also free parking available in the back of our office building, which can be accessed by using Sheridan Avenue, turn at the Pizza Hut sign on Lincoln Ave. We look forward to meeting you. Welcome to our practice! Sincerely, Dr. John B. DeBonis Page 1
2 Patient Registration Full Name: Preferred Name: Address: Home Address: City: State: Zip: Cell Phone: Work Phone: Dob: SS#: Marital Status: Pharmacy: Phone: Person Responsible for Account: Emergency Contact: Phone: How did you hear about our office? Primary Dental Insurance Coverage Please be sure to check your insurance is NOT A DMO, DMHO Or HMO Plan Subscriber Name: Relation to Patient: SS#: D.O.B.: Employer: Dental Insurance Company: Subscriber #: Group #: Page 2
3 Dental History 1. Do you have dental examinations on a routine basis? 2. Do you think you have active decay or gum disease? 3. Do you brush and floss on a routine basis? 4. Do your gums ever bleed? 5. Does food catch between your teeth? 6. Any loose teeth? 7. Do you ever have clicking, popping or discomfort in the jaw joint? 8. Do you BRUX or grind your teeth? 9. Do you have any sores or growths in your mouth? 10. Have your past experiences in a dental office always been positive? 11. Are you pregnant? 12. Are you nursing? 13. Do you smoke or use tobacco? 14. Name of previous dentist: 15. Do you have a specific dental problem? 16. Date of last full mouth x-rays or panorex: Height: Weight: Allergies (Please list all items that may apply) Medications Page 3
4 Medical History YES NO YES NO Abnormal bleeding Glaucoma Alcohol/drug abuse HIV+ Aids Allergies (Medicines) Hay fever/allergies Anemia Heart murmur Angina/Chest Pain Heart pacemaker Arthritis/Gout Heart trouble/disease Artificial heart valve Hepatitis A, B or C Artificial joint High blood pressure Asthma High Cholesterol Blood disorders Kidney problems Bruise easily Liver disease Cancer-Chemotherapy Low blood pressure Congenital heart defect Mitral valve prolapses Daily aspirin regimen Need Premedication? Diabetes/Hypoglycemia Osteoporosis/Osteopenia Difficulty breathing Radiation therapy Emphysema/lung disease Recent weight change Epilepsy Rheumatic/scarlet fever Excessive thirst Seizures Fainting or dizziness Sexually transmitted disease Page 4
5 HIPAA Acknowledgement I have received and reviewed a copy of our dental practice s privacy, security and breach notification policies and procedures. I understand that I should ask our dental practice s Privacy Official if I have any questions about these policies and procedures. Print Name: Signature: Date: Policy Agreement Appointments: In order to serve you better and keep the cost of dental care down, we try to maintain an efficient appointment system. However, our cost of providing care increases greatly when people fail to keep scheduled appointments or cancel at the last minute. We require at least 48-hour notice for any cancelled appointment. At the time of any cancellation under 48-hours, we will apply a $50.00 fee. After 3 missed appointments or cancelled appointments we will place you on a short call list, which means we will phone you when an appointment time becomes available on short notice. This gives you the opportunity to know if your busy schedule has an opening for a dental appointment within the next few hours. Insurance Information: As a courtesy to our insured patients, we submit claims to your insurance company free of charge. We will help you to receive your maximum allowable benefits. In order to do this, we need your insurance card and/or insurance policy with you on your first visit of every calendar year (your insurance year may not run January December) All of our doctors will diagnose treatment based on your dental health not your insurance coverage. If your insurance has not paid within 90 days of services rendered, you will need to make full payment to this office and you will be reimbursed when your insurance company pays. After 90 days, the patient is responsible to pursue payment from the insurance company. All current documentation will be provided by mail in order to assist your inquiries. The insured has a better ability to deal with the insurance company and the employer responsible for the policy. Please indicate your understanding and acceptance of these financial policies by signing below. For the mutual convenience of you and the practice, it is understood that this executed copy of the Financial Policy also shall cover your dependent children who are patients of the practice. Patient/ Guardian Signature: Date: Page 5
Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
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Please print name and Relationship to patient Dental/Medical History Are you having pain or discomfort at this time? Y N Do you feel very nervous abou
Personal Information Patient Registration Form Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Email Address Birthday Sex: M F Marital Status: S M W Sep D Social Security
Primary Insurance Information
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Patient Signature (parent if minor): Date:
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PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
PATIENT REGISTRATION
ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred Name: Last Name: Middle
Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:
Dental History Medical History Reason for today s visit: _ Former Dentist:_ Date of last dental visit_ Date of last dental x-rays_ Mark Yes or No to indicate if you presently have or previously had any
DENTAL REGISTRATION AND HISTORY
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Patient Registration PATIENTS WITH DENTAL INSURANCE ALL THIS INFORMATION IS NECESSARY TO VERIFY YOUR DENTAL COVERAGE!!
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Dental Registration and History
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PATIENT REGISTRATION
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Address Who referred you to our practice? relationship
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PATIENT REGISTRATION
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Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
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Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred
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12. Is there anything we can do to enhance your smile and optimize your oral health? Yes No Tell us more:
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PATIENT REGISTRATION
TIME 10:44 AM DATE 7/12/2011 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
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PATIENT REGISTRATION
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New Patient Paperwork
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PATIENT REGISTRATION
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Lowrance Dental REGISTRATION FORM (Please Print)
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PATIENT REGISTRATION
TIME 2:51 PM DATE 6/26/2013 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
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What types of care are you most interested in? Please check all that apply: Cleaning Crowns Implants Braces Dentures Teeth bleaching Pain relief
Client Information Name Preferred Name Address Birthdate City, Zip Code S.S.N Home Phone Work Phone Cell Employer Occupation Location May we contact you at work? Yes No When is the best time to contact
Responsible Party Information
3521 COMMERCE CT APPLETON, WI 54911 (920)-734-7730 WELCOME TO OUR PRACTICE Patient Name Preferred Name (Last Name) (First Name) (MI) Gender: Male / Female Family Status: Minor / Single / Married / Other
WELCOME TO OUR PRACTICE
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Name. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address
405 S. Granite Ave. PO Box 959 Granite Falls, WA 98252 tel (360) 691-7793 fax (360) 691-5577 www.cervendentistry.com To help us better serve the needs of your child and meet his/her dental healthcare needs,
Patient Registration
Patient Registration Date: First Name Last Name Middle Initial Preferred Name E-mail Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers
REGISTRATION FORM Section I: Patient Information. Date: Name: SSN: - - Date of Birth:
REGISTRATION FORM Section I: Patient Information Date: Name: SSN: - - Date of Birth: Address: City: State: Zip: Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Minor Single Married Widowed Separated Divorced
538 SAVANNAH HIGHWAY CHARLESTON, SC (843)
DENTAL HISTORY Name: Reason for today s visit: Previous dentist: Previous dentist s phone number: Date of last dental care: Last dental x-rays: Please indicate any of the following issues that apply with
Patient Information. Date: Last First MI
1320 South Lapeer Road Lake Orion, Michigan 48360 (248) 693-6213 Patient Information Patient Name: Date: Last First MI Male Female Married Single Child Other Birth Date: Social Security #: Driver s License
Patient Information. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
Patient Information. Patient s Name: Preferred Name: Date of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status:
Patient Information Today s Patient s Name: Preferred Name: of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status: Employer: Occupation: Spouse s Name: Spouse Employed by: Business Phone: