NAME AND PHONE NUMBER OF PHARMACY:
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1 Emil W. Tetzner, D.M.D., M.S. Practice Limited to Periodontics *Please complete both sides AND MAIL BACK TO OUR OFFICE* Name Street City & State Zip Code Home Phone Business Phone Cell Birth Date M F Height Weight Emergency Contact Name & Phone number Date Employer Occupation Social Security Number General Dentist Referred By Physician Marital Status Spouse or Parent s Name MEDICAL HISTORY NAME AND PHONE NUMBER OF PHARMACY: Note to patient: These questions are for your benefit. This information will assist us in your diagnosis and treatment. Please check any of the following that apply to you: Heart trouble Diabetes Tuberculosis Congenital Heart trouble Jaundice Kidney Disease Heart Murmur\Echo Hepatitis Arthritis Heart Surgery Cancer Stomach Ulcers Rheumatic Fever Glaucoma Stroke Cardiac Pacemaker Sinus Trouble Epilepsy Persistent Cough Heart Valve Prosthesis Psychiatric Care High Blood Pressure Asthma Child Births HIV infection Low Blood Pressure Blood Transfusion Thyroid Disorder Joint replacement Alcohol/Drug addiction High Cholesterol Sexually Transmitted Diseases 1. Have you had a recent physical examination When? Lab Work When? 2. Has there been any change in your general health in the last year? Explain 3. Have you been under a doctor s care, been hospitalized or seriously ill during the past two years? Explain: 4. Do you take any medications or drugs, including aspirin, vitamins, hormones, antacids, steroids or birth control pills presently or within the last six months? Please list below. DRUG DOSE & FREQUENCY 5. Are you allergic to or have you experienced an unusual reaction to drugs? Please list? 6. Have you experienced any other allergic reactions? Please list: 7. Have you experienced excessive bleeding that required special treatment? 8. Have you ever pre-medicated for a dental appointment? Do you pre-medicate now? Explain: 9. Is there a history of diabetes in your immediate family? 10. Are you required to restrict your diet, work or activities in any way? 11. Do you smoke cigarettes? Cigars? Pipe? How many per day? For how long? 12. Have you ever been treated for a growth or tumor in any part of your body? Explain: 13. Are you under a great deal of stress on a daily basis, or has your daily stress increased? Explain?
2 14. Do you have frequent headaches? Migraines? What area of the head? Duration? 15. Do you have any disease, condition or problem that you feel we should know about? If yes, explain: Women: 16. Are you pregnant? Due date? Is your menstrual cycle regular? 17. Have you reached menopause? 18. Are you having any menopause symptoms? Please list: DENTAL HEALTH HISTORY Check any of the following which you may have had or experienced: Injury to face or jaw Sensitive to Hot Aches in Jaw Joint Slow-healing mouth sores Sensitive to Cold Clicking/Popping in Jaw Fever Blisters Mouth Odor Jaw locking-open or closed Mouth Ulcers Bad taste in mouth Change in bite Swollen gums Loose teeth Tired or sore muscles Clench or grind teeth Which of the following do you do on a daily basis? Times Brush a day (Soft/Medium/Hard Bristles ) Times Floss a day Mouthwash (what type) how often? 1. If you are currently experiencing pain in your mouth, where is it located? 2. How did it come to your attention that you have a periodontal problem? 3. Do you feel strongly about keeping your teeth for the rest of your life? 4. Are you happy with the appearance of your teeth? 5. Have you had orthodontic therapy (braces)? Type? When? 6. Have you had previous periodontal (gum) treatment? Type? When? 7. Have you had oral surgery? Type? When? 8. Have you had crown and/or bridgework? When? 9. Have you ever worn a bite plane or night guard? When? 10. Have you ever noticed a change in the position of your teeth? Explain? 11. Do you have any difficulty in chewing? Explain? 12. Is it difficult to open your mouth wide? 13. Are you worried about receiving dental treatment? If so, what is your main concern? Present dentist: How long? Last Dental treatment: Type of treatment? Last Cleaning: Last x-rays: Pattern of Dental care: regular (every months) sporadic infrequent Signature Date
3 * Please complete both sides * Practice Limited to Periodontics NEW PATIENT INFORMATION FORM Last Name: First: Middle: Preferred Name: Title: Home Address: Home Phone: Work Phone: Sex: F M DOB: SS#: - - Marital Status: Employer Name and Address: Referring Dr: Referring Patient: Medical Alerts: PRIMARY DENTAL COVERAGE Subscriber Name and Address: Relationship to Patient: SS#: - - DOB: Employer Name and Address: Insurance Company Name and Address: ID#: Group#: SECONDARY DENTAL COVERAGE Subscriber Name and Address: Relationship to Patient: SS#: - - DOB: Employer Name and Address: Insurance Company Name and Address: ID#: Group#: RESPONSIBLE PARTY FOR PATIENT You are responsible for the bill regardless if your insurance covers any of the treatment provided. Payment is expected when services are rendered unless prior arrangements have been made. Signature: Date:
4 * Emil W. Tetzner, DMD, MS, PA Specializing in Periodontics and Implantology OFFICE POLICY DENTAL INSURANCE AND FINANCIAL ARRANGEMENTS 1. Patients are responsible for fees incurred 2. Patient payment, for the first visit, is due at the time of service ($165.00), Insurance will be filed if applicable and adjustments made to the account when and if payment is received from insurance 3. For treatment requiring several visits, estimate of proposed services can be sent to insurance, so that financial arrangements can be made ahead of time i 4. If we do not participate with your insurance you are responsible for any amount the insurance does not pay 5. As a courtesy to you, we will submit insurance forms for patients. Please note there are certain insurances who pay the patient directly, in which case, payment is due from the patient the day services are incurred 6. Pre-determination are done upon request 7. For the remainder of patients with insurance a down payment of 20-50% is required at the time of service. Unlike medical insurance, most dental plans do not cover 100% of charges incurred so after insurance pays the claim we will bill you for any difference due 8. Unpaid balances over 90 days will incur a monthly handling charge of 1.5% monthly (18% A.P.R.) 9. We accept checks, cash, Master Card, Visa and Discover 10. We accept CARECREDIT for balances: Up to $ at 0% interest Over $900 - $ % interest (24 to 48 months) Over $ % interest (60 months) Please be advised that for liability reasons we are unable to have children accompany you in the room while procedures are being completed. Please make arrangements for children to be left at home. If you arrive with your child, your appointment will need to be rescheduled. Please do not hesitate to ask us any questions regarding our office policies. We want you to be comfortable in dealing with these matters and we urge you to contact us if you have any questions regarding these issues. I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE OFFICE POLICIES. Patient s/parent s Signature Date * updated 4/20/15
5 i Pre-determinations to insurance are done upon patient request (Emil W. Tetzner, DMD MS) 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 Patient s Name) (Signature) (Date) 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 Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)
6 Emil W. Tetzner, DMD, MS, PA OUR APPOINTMENT GUIDELINES When you schedule an appointment, we reserve that time just for you with our dental staff and doctor. We are committed to honoring the appointment time of our scheduled patients, so it is critical that you confirm your appointment within 24 hours of your appointment and that you arrive on time. We require verbal confirmation of your appointment, please call the office to confirm your appointment. If you do not confirm your appointment we can only assume you are not coming to the appointment and we will remove you from the schedule. 1) You will receive a post card reminder two weeks prior to your appointment. Feel free to call us and confirm your appointment at that time. 2) Three days prior to our appointment you will receive a confirmation call asking you to return our call to confirm your appointment. 3) If your appointment is not confirmed 2 days prior to your appointment we will make another attempt to confirm your appointment. If you have not confirmed your appointment at least 1 day prior to your appointment we will assume you are not coming and we will have to give your appointment to another patient. We will cancel your appointment if you cannot be reached because of disconnected phone, if we are unable to leave a message, and you do not contact the office. Please inform us of any changes in your contact information. We understand that circumstances occur that do not allow you to keep your scheduled appointment. In this case, please call us at least 48 hours in advance of your appointment time to reschedule your appointment.. If you are more than 10 minutes late for an appointment, you will need to be rescheduled. If you miss your appointment without cancelation, you will not be rescheduled. A surgical appointment cancelled without 48 hours notice will be charged a $ fee. We do understand emergencies and illness occur and are taken into consideration. Patient Signature Date
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
Welcome Thank you for choosing us for your dental care needs. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to contact us. (206)
Welcome to CitiDental
Date: Welcome to CitiDental Patient Information: Name D.O.B. SS# Address Apt Town State Zip Marital Status Home Phone Cell# Other Email Employer Work Phone EMERGENCY CONTACT: Name Phone Responsible Party:
Lasting Impressions Dentistry Sabrina Habib Heppe DDS, PS (206)
Personal Information Last Name First Name Pref. Name MI Mailing Address Apt # City State Zip Home# ( ) Cell# ( ) Sex: M F E-Mail: Confirmation of Apts by Email? Yes No Date of Birth / / SSN#: Marital Status:
PATIENT INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed E-mail address:
Candace L. Peterson, DMD
Candace L. Peterson, DMD PATIENT REGISTRATION Date A. Responsible Party SS # - - Last First Middle Home Address Birthdate E-mail City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Employer
Lowrance Dental REGISTRATION FORM (Please Print)
Today s Date: Patient s last name: First: Middle: Lowrance Dental REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Is this your legal name?
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Welcome Date / / Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Patient s Name Last First M.I. Address City State Zip Code Home Phone
PERSONAL INFORMATION
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
GRAND STRAND DENTISTRY B Hwy 544. Conway, SC 29526
GRAND STRAND DENTISTRY 1867 B Hwy 544 Conway, SC 29526 I,, hereby authorize Grand Strand Dentistry to give the following people information concerning my health, treatment, billing and/or insurance information:
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: SINGLE
Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
247 River Vista Place Suite 200 Twin Falls, Idaho 83301 www.twinfallssmiles.com (208) 734-8080 PATIENT REGISTRATION Name: Preferred Name: Address: Home Phone: Work Phone: Cell Phone: Email: Can we contact
Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:
David B. Epstein DDS 1 0 0 1 M E D I C A L P L A Z A D R # 3 0 0, T H E W O O D L A N D S, T X 7 7 3 8 0 281-367- 3 0 8 5 d r e p s t e i n @ t h e w o o d l a n d s d e n t a l. c o m Patient Information
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
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
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD Patient Information Name Preferred Name [ ] Male [ ] Female First MI Last SS# Birth Date Status
WELCOME TO OUR PRACTICE
WELCOME TO OUR PRACTICE We will like to know your dental concerns and expectations so we can provide you with the best dental care. What are your dental concerns? What would you like to improve, if anything,
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Date / / Welcome Patient s Name Last First M.I. Address City State Zip Code Home Phone
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
Dr. Víctor Vergara DMD P.A Livingston Rd, Bldg # 100, Ste. #106, Naples, FL Fax PATIENT HEALTH RECORD
! Dr. Víctor Vergara DMD P.A. 239-263-0912 13180 Livingston Rd, Bldg # 100, Ste. #106, Naples, FL 34109 Fax 239-263-0925 PATIENT HEALTH RECORD PATIENT INFORMATION Date (Month/Day/Year) / / DATE OF BIRTH
Prince Family Dentistry
Prince Family Dentistry 702-240-0202 830 S. Durango Dr., Ste. 104 Las Vegas, NV 89145 PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married {
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
Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Address
Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Home Phone Daytime/Work
NEW PATIENT REGISTRATION FORM (PLEASE PRINT)
NEW PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT INFORMATION Full Legal Name (First) (Middle) (Last) Preferred Name (Nickname) Address Apt. No. City State Zip E-mail Home Phone: Work Phone Cell Phone:
Georgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
DENTAL REGISTRATION AND HISTORY
DENTAL REGISTRATION AND HISTORY 1. PATIENT INFORMATION Date Patient Name Last Name First Name Middle Initial Address E-mail City State Zip Sex M F Age Birth date Married Widowed Single Minor Separated
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
18121 E Hampden Ave, Unit E Aurora, CO
18121 E Hampden Ave, Unit E Aurora, CO 80013 303-848-4929 Patient Information Name: E-Mail Address: Male Female Gender: Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Home Address: Date of Birth: / /
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:
Patient Information. Patient Name: Preferred Name: Birthdate: SSN: Home Phone: Cell Phone:
We are pleased to welcome you to our office. Please take a few minutes to fill out your patient information forms as completely as you can. We d be glad to help if you have any questions. Patient Information
Anthem Hills Dental PATIENT INFORMATION
PATIENT INFORMATION Patient Name DOB Date Address City ST Zip Preferred Contact # Home # Cell # E-mail _ SSN Marital Status: S M Other Employer Type of Work Work # Business Address_ City ST Zip Emergency
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS OR CONCERNS? (Circle all correct responses)
Name How do you wish to be addressed of Birth Reason for today s visit Former dentist Reason for leaving of last dental visit Reason for last dental visit How often do you brush? How often do you floss?
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
Brighter Smiles Family Dentistry
Brighter Smiles Family Dentistry Welcome To Our Office! Our team believes that our patients are the most important people in the world. We appreciate that you have chosen our team as your dental family.
WELCOME TO LEHIGH DENTAL
WELCOME TO LEHIGH DENTAL The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate,
Welcome to Family Tree Dental Care Midway Rd., Ste 106A Farmers Branch, TX 75244
Patient Information: Patient s Name: Address: City, Zip Code: Email address: Sex: M/F SSN: Date of Birth: Age: Marital Status: Home Phone: Cell Phone: Work Phone: Responsible for Account/Subscriber/Guardian
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
LONDON BRIDGE SMILES Patient Information (please print) Name Social Sec. # Date of Birth Male/Female First MI Last Address City State Zip Home Phone Cell Phone E-mail Employer Occupation Work Phone Business
Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
![Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell](/thumbs/95/122853379.jpg "Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell")
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
Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
Name: Last First Middle. Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Street City State Zip
PATIENT INFORMATION Name: E-mail: Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / Social Security Number: - - Driver s License #: RESPONSIBLE PARTY INFORMATION
Dental Registration and History
~) Patient Information (PLEASE PRINT) ftj. Dental Insurance Date Who is responsible for this account? SS/HIC/Patient ID # Relationship to Patient. Patient Name----,------,--,-, Last Name Insurance Co.
WELCOME TO PRAIRIE GARDEN DENTAL. Responsible Party/Primary Insurance Holder If different from above
WELCOME TO PRAIRIE GARDEN DENTAL Patient Information Date Name Preferred Name Birthdate Social Security # Female Single Married Divorced Widowed Separated Other Home Address Employer Occupation Home Phone
Patient Information. Date of Birth Social Security # Primary Contact Number? Home Cell Work. Dental History. Reason for today s visit
Patient Information Michael G. Paat, DMD First name Middle Initial Last name Address City State ZIP Date of Birth Social Security # Home phone Cell phone Work phone Primary Contact Number? Home Cell Work
Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc. Birth Date: Social Security # Previous Visit Date
Welcome to Dr. Peer s Office New Patient Registration Form Patient Name: Last First MI Preferred Name Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc Birth Date: Social
Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n
Shore Smiles Family & Cosmetic Dentistry 654 Newman Springs Road, Lincroft, New Jersey 07738 Phone: 732-747-4444 Fax: 732-747-4003 Welcome Take a few minutes to answer the following questions so we can
Patient Information. Your Name: Name you wish to be called: Date: Physical Address: Street Name and Number City Zip Code
Patient Information Welcome to Rivery Dental. Thank you for choosing our office for your dental care. Our primary goal is to help you achieve and maintain your maximum oral health with a smile you are
YOUR FIRST APPOINTMENT IS ON AT.
DWAYNE KIM MARTIN, D.D.S., M.S. HILLTOP PROFESSIONAL BUILDING 1855 SAN MIGUEL DRIVE, SUITE 21 PERIODONTICS AND DENTAL IMPLANTS WALNUT CREEK, CALIFORNIA 94596 (925) 932-1422 FAX (925) 932-2020 Email: martinperio@sbcglobal.net
Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone
Patient Information NameSoc. Sec. # Last Name First Name Middle Initial Address City State _ Zip _ Home Phone _ Cell Phone _ Sex M F Birthdate _ Single Married Widowed Separated Divorced Patient Employed
Address Who referred you to our practice? relationship
Health History Form Date Name Home Phone ( ) Cell ( ) Work ( ) Address City State Zip Code Occupation Height Weight Date of Birth Sex M F SS# Emergency Contact Relationship Phone ( ) E-mail Address Who
Patient Information & Demographics
ARTISTRY INTEGRITY PASSION 101 NORTH MARY STREET HEDGESVILLE, WV. 25427 NEW UPDATE Patient Information & Demographics Appointment : Appointment Time: am pm Name: Nickname: Address: of birth: SS# Marital
WELCOME! Patient Information:
WELCOME! Patient Information: 10220 Medlock Bridge Rd. Suite 100 Johns Creek, Ga. 30097 Name: Last First MI Mailing Address: Phone #: (C) (W) (Other) Date of Birth: SSN: Sex: Male Female Marital Status:
Welcome. Name Perferred name Last First MI Mr Mrs Ms Dr Birthdate Social Security Number Single Married Divorced Widowed
Welcome Thank you for choosing to visit our dental office. It is our pleasure to meet you! In order to serve you best, please take a moment to provide us with some important information. Your responses
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address:
New Patient Information
New Patient Information Name: : What name would you like to be called?: of Birth: Home Phone: Social Security No: Cell Phone: E-mail: Address: City: State: Zip: Employer: Work Address: City: State: Zip:
Primary Insurance Information
Durell Family Den-stry Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you.
117 FLORAL VALE BLVD, YARDLEY, PA PHONE: FAX: PATIENT INFORMATION
117 FLORAL VALE BLVD, YARDLEY, PA -19067 EMAIL: radiantsmiles2009@yahoo.com PHONE: 215-860-4600 FAX:215-860-1455 PATIENT INFORMATION Patient s Name: (Last) (First) (MI) Address: (Street/Apt.) (City) (St)
Patient Information. Male Female Married Single Child Other. Health Information
Patient Name Patient Information Last, First MI (Preferred Name) D ate: Social Security #: Birth Date: Driver s Lic #: Cell phone Phone (Home): (Work): Ext: Address: Street Apartment # City State Zip Code
PATIENT REGISTRATION
PATIENT REGISTRATION First Name: Last Name: Middle Initial: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle
Patient Information. Patient Name: ( ) Last Name, First Middle Preferred Name
THOMAS H. WILLIAMS, D.M.D., P.C. Restorative, Cosmetic, & Implant Dentistry Phone (334) 277-9570 Fax (334) 277-0152 Email: office@ thwilliams.com Website: www.thwilliams.com New Patients: Please return
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
PATIENT REGISTRATION
PATIENT REGISTRATION ID: Chart ID: First Name: Last Name: Middle Initial: Patient is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient) First Name: Last
Patient Information:
Patient Information: Today s Date: Name: Preferred Name: Date of Birth: / / Age: SS# Driver License# Home Address: City Zip Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email: Employer Address
Today's Date: PRIMARY INSURANCE Name: Subscriber's Name:
The following questions are about the insurance subscriber(s): Today's Date: PRIMARY INSURANCE Name: Subscriber's Name: Preferred Name: Date of Birth: Gender: Single Married Child Other Phone Number: Date
Scott K. Smith, D.D.S. 357 S Gulph Road, Suite 250 King of Prussia, PA
FOR OFFICE USE ONLY: (PREMED) (ALLERGIES) (MEDICATIONS) (CHIEF COMPLAINT) PATIENT INFORMATION AND HEALTH HISTORY Today s Date / / Patient s Name (Mr. Mrs. Ms. Dr.) Birth Date (Age) / / ( ) Sex Marital
Patient Information. Health Information
Henritze Dental Group 4119 Brandon Ave. SW ROANOKE VA, 24018 (540) 776-6555 Email: brandon@henritzedental.com Website: www.henritzedental.com Steven N. Anama, DDS Patient Information Patient Name: Date:
WELCOME PATIENT INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we ll be glad to help you. We look forward to working
Jeffrey R. Wert, D.M.D., P.C.
Jeffrey R. Wert, D.M.D., P.C. Patient Registration Form Date: Patient Name: Birthdate: Sex: M F Address: Email Address: Home Phone: SSN: - - Marital Status: S M D W Cell Phone: Employer: Work Phone: Ext:
Drs. Ellis, Green and Jenkins
Drs. Ellis, Green and Jenkins WELCOME TO OUR PRACTICE Patient Information Today s : First Name: MI: Last Name: _ Birthdate: Age: SS#: _ Marital Status: Married Single Widowed Divorced Separated Address:
YOUR CHILD'S PERSONAL INFORMATION. RESPONSIBLE PARTY (Person responsible for Child's Account)
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Jane Otto Family Dentistry Gravois Road St. Louis, MO (314)
Jane Otto Family Dentistry 11521 Gravois Road St. Louis, MO 63126 (314) 842-2442 PATIENT INFORMATION Patient Name: Last First MI Male Female Married Single Child Other: Social Security #: Date of Birth:
Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
PATIENT REGISTRATION AND HISTORY
PATIENT REGISTRATION AND HISTORY Today s Date: Patient s Name DOB: Sex: Male Female If a Child, Parent s Name: Who does child reside with (name and relationship): Home Address: City: State: Zip: Home Phone
New Patient Registration
New Patient Registration Appointment date & time: Patient Name: Birth date: SS #: Mailing Address (if different:) Phone 1: Hm Cell Wk Phone 2: Hm Cell Wk Email: Patient is a college student. Name of college/university:
1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information
Patient Information Patient s Last Name First Name Middle Initial Preferred Name Responsible Party s Name (if not patient) Relationship to the patient Today s Date Family Status: Single Married Divorced
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
Bozart Family Dentistry
Bozart Family Dentistry Gentle Compassionate Understanding Albert T. Bozart, D.D.S. Date Appointment Date Time PATIENT INFORMATION: Name Birthdate SS# Sex M F Married Widowed Single Minor Separated Divorced
Medical History. Notes:
PATIENT NAME MEDICAL ALERTS Medical History Preferred Pharmacy location: Pharmacy #: Have you taken any medication/drugs during the past two years? Are you taking any medications, drugs, or pills now?
Acknowledgement of Receipt of Notice of Privacy Practices
HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
Dental/Medical History Form
Dental/Medical History Form Name Social Security # / / FIRST MIDDLE LAST Date of birth / / Age Male/ Female Status: Married /Single /Divorced / Widowed / Separated Address City State Zip Home Phone ( )
DENTAL REGISTRATION AND HEALTH HISTORY
DENTAL REGISTRATION AND HEALTH HISTORY PATIENT INFORMATION Soc. Security #/Patient ID #: Patient Name: Gender: Date of Birth: Age: E-mail: Phone (Home): (Work): Ext: (Cell): Address: City: State: Zip:
Patient Information. Dental Insurance. Emergency Contact
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we ll be glad to help you. Patient Information Date Patient
❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
Patient Signature (parent if minor): Date:
Patient Information Patient Name Mailing Address City State Zip: Home Phone: Cell Phone: Work Phone: Email: Birth Date: / / Age: Sex: Male Female Social Security: Drivers License: Emergency Contact: Phone
PLEASE COMPLETE THE FOLLOWING INFORMATION
PLEASE COMPLETE THE FOLLOWING INFORMATION PATIENT INFORMATION: Name: Birth Date: Age: Address: Social Security #: City: State: Zip: Drivers License #: Employer: Home Phone #: Business Address: Work Phone
Patient Name Preferred Name Social Security. Address City, State, Zip. Home Phone Work Phone Cell Phone. Birth Date Age Driver s License #
Welcome To Our Office! Thank you for choosing us as your dental care provider. We are dedicated to providing you the best dental care. If you have any questions while completing the form, we will be happy
Dell A. Goodrick, DDS, FAGD
PATIENT INFORMATION DATE NAME MARRIED SINGLE CHILD MALE FEMALE SOCIAL SECURITY / PATIENT ID BIRTHDATE ADDRESS CITY STATE ZIP PHONES: HOME WORK CELL EMAIL PREFERRED METHOD OF CONTACT PATIENT EMPLOYER F/T
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
ADULT PATIENT INFORMATION. Gender: Male/Female. Patient s name Last First Middle Residence Street City Zip Mailing Address Street City Zip
ADULT PATIENT INFORMATION Date Gender: Male/Female Patient s name Last First Middle Residence Street City Zip Mailing Address Street City Zip Home Phone: Work Phone: Cell Phone Birthdate Social Security
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
Responsible Party Information
Patient Information Date Male Female Married Single Divorced Separated Student Last Name First Name Middle Address City State Zip E-mail Address Social Security # Date of Birth Home # Work # Cell # Employer
Patient Registration
Patient Registration ID: Chart ID: First Name: Last Name: Middle Initial: Patient is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient) First Name: Last
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
HEALTH HISTORY. Physician s Name Phone# Date of Last Visit
HEALTH HISTORY Physician s Name Phone# Date of Last Visit Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combination of Ionamin, Adipex, Fastin (brand
WELCOME TO OUR PRACTICE
Chart# WELCOME TO OUR PRACTICE On behalf of entire team at A Great Smile Dental, let me welcome you to our practice. We are grateful that you have chosen us to meet your dental needs, and trust that you
Driver s License # Cell Phone Gender Male Female. Single Married Divorced Other. Driver s License # Cell Phone Gender Male Female
Patient Information: Patient Name Home Address City, State, Zip Home Phone Social Security # Birthdate Driver s License # Cell Phone Email Gender Male Female Work Phone Insurance Information: Marital Status
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,