PATIENT REGISTRATION. Last Name: Preferred Name: Address 2: Address 2: Work Phone: Ext: Cellular: Insured Birth Date. Ins.
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1 ID: First Name: Patient Is: Policy Holder 1 Responsible Party Chart ID: PATIENT REGISTRATION Last Name: Preferred Name: Middle Initial: First Name: Last Name: Middle Initial: City, State, Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Birth Date: Soc Sec: Drivers Lie: O Responsible Party is also a Policy Holder for Patient O Primary Insurance Policy Holder O Secondary Insurance Policy Holder i-patient Information City. State/Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Sex: Q Male O Female Marital Status: O Married O Sing e O Divorced Q Separated O Widowed Birth Date: Age: Soc. Sec: Drivers Lie: O 'would like t0 receive correspondences via . Section 2 Employment Status: Q Full Time O PartTime O Retired Additional Comments: Student Status: Medicaid ID: Q Full Time O PartTime Pref. Dentist: Employer ID: Pref Pharmacy: Carrier ID: Pref. Hyg.: r-primary Insurance Information Name of Insured: Relationship to lnsured:q Self O Spouse O Child O Other Insured Soc. Sec: Insured Birth Date Employer: Ins. Company: Rem. Benefits:.00 Rem. Deduct:.00 [-Secondary Insurance Information- Name of Insured: Relationship to InsuredO Self O Spouse O Child O Other Insured Soc. Sec: Insured Birth Date Employer: Ins. Company: Rem. Benefits:.00 Rem. Deduct:.00
2 Pleasant Dental Center MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? O Yes O No Have you ever been hospitalized or had a major operation? Q> Yes O No Have you everhad a serious heador neckinjury? O Yes O No Are you taking any medications, pills, ordrugs? O Yes O No Do you take, or have you taken, Phen-Fen orredux? Q Yes O No Have you ever taken Fosamax, Boniva, Actonel orany other s~\y On medications containing bisphosphonates? w es w Are you on a special diet? O Yes O No Do you use tobacco? O Yes O No Do you use controlled substances? O Yes O No Women: Are you If yes, please explain: Ifyes, please explain: If yes, please explain: If yes, please explain: Pregnant/Trying toget pregnant? Q Yes O No Taking oral contraceptives? Q Yes O No Nursing? O Yes O No Are you allergic to any of the following? ] Aspirin J Penicillin ] Codeine ] Other Ifyes, please explain: Do you have, or have you had, any of the following? j Local Anesthetics ] Acrylic LI Metal Latex J Sulfa drugs AIDS/HIV Positive O Yes O No Cortisone Medicine O Yes O No Hemophilia O Yes O No Radiation Treatments O Yes O No Alzheimer's Disease O Yes O No Diabetes O Yes O No Hepatitis A O Yes O No Recent Weight Loss O Yes O No Anaphylaxis O Yes O No Drug Addiction O Yes O No Hepatitis B or C O Yes O No Renal Dialysis O Yes O No Anemia O Yes O No Easily Winded O Yes O No Herpes O Yes O No Rheumatic Fever 0 Yes O No, Angina O Yes O No Emphysema O Yes O No High Blood Pressure O Yes O No Rheumatism O Yes O No Arthritis/Gout O Yes O No Epilepsy or Seizures O Yes O No High Cholesterol O Yes O No Scarlet Fever O Yes O No Artificial Heart Valve O Yes O No Excessive Bleeding O Yes O No Hives or Rash O Yes O No Shingles O Yes O No Artificial Joint O Yes O No Excessive Thirst O Yes O No Hypoglycemia O Yes O No Sickle Cell Disease O Yes O No Asthma O Yes O No Fainting Spells/DizzinessO Yes O No Irregular Heartbeat O Yes O No Sinus Trouble O Yes O No Blood Disease O Yes O No Frequent Cough O Yes O No Kidney Problems O Yes O No Spina Bifida O Yes O No Blood Transfusion O Yes O No Frequent Diarrhea O Yes O No Leukemia O Yes O No Stomach/Intestinal DiseaseO Yes O No Breathing Problem O Yes O No Frequent Headaches O Yes O No Liver Disease O Yes O No Stroke O Yes O No Bruise Easily O Yes O No Genital Herpes O Yes O No Low Blood Pressure O Yes O No Swelling of Limbs O Yes O No Cancer O Yes O No Glaucoma O Yes O No Lung Disease O Yes O No Thyroid Disease O Yes O No Chemotherapy O Yes O No Hay Fever O Yes O No Mitral Valve ProlapseO Yes O No Tonsillitis O Yes O No Tuberculosis O Yes O No Chest Pains O Yes O No Heart Attack/Failure O Yes O No Osteoporosis O Yes O No Tumors or Growths O Yes O No Cold Sores/Fever Blisters O Yes O No Heart Murmur O Yes O No Pain in Jaw Joints O Yes O No Congenital Heart DisorderO Yes O No Heart Pacemaker O Yes O No Parathyroid Disease O Yes O No Convulsions O Yes O No Heart Trouble/Disease O Yes O No Psychiatric Care O Yes O No Have you ever had any serious illness not listed above? O Yes O No Comments: Ulcers Venereal Disease Yellow Jaundice O Yes O No O Yes 0 No O Yes O No -- 1 To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE
3 GEORGE ABGU-EZZL D.M.D. CHRISTA RIZKALLAH, D.M.D. Pleasant Cental &mtor 126A Pleasant QPallcp Q&iwci, QhtotcA&km OWA 018# 'VShom (978) (jfas, (978) GLmail: not Informed Consent For General Dental Procedures You the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist,you may increase the chancesof a pooroutcome. Please read and initial the items below and sign at the bottom ofthe form. 1. Treatment to be provided I understand that during my course of treatment that the following care may be provided: Examinations Preventative Services Periodontal Treatment Restorations Root Canal Local Anesthesia Removable Appliances Crowns Bridges 2. Drugs and Medications Patient Initials I understand that antibiotic, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). 3. Changes in Treatment Plan Patient Initials I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restoratives procedures. I give my permission to the dentist to make any/all changes and additions as necessary. Patient Initials Patient name (please print) Signature (patient, parent or guardian) Date
4 GEORGE ABOU-EZZI, D.M.D. CHRISTA RIZKALLAH,, D.M.D. Pleasant Cental &enter 126A Pleasant Valley Street. Suite 4 * Mcthuch, MA * Phone: (978) Fax: (978) * pleasantdentalcenter@comcast.net Cell Phone Use Policy Nowadays, leaving an appointment reminder on a home phone is no longer an effective way to reach our patients. Simply, because many patients no longer check their voice mail systems and rely exclusively on cell phone communication. However, before our office makes the switch, please provide your consent below, 1. I provide the consent to Pleasant Dental Center to use my cell phone number to o Call o Text regarding appointments o Leave a message 2. I consent to Pleasant Dental Center to call using my cell phone regarding dental treatment, insurance, and my account. I understand that I can withdraw this consent at any time. My phone number is Patient Signature: Date:
5 GEORGE ABOU-EZZI, D.M.D. HRISTA RIZKALLAH, DM.D. Pleasant Cental &mter I26A isleasattl QPaOp Qtblrccl, Q&uite 4 ometkum, OUA lbh*t* (978) ^a, (978) *9 GSjnbL plcascaitcknudccnlcr&comcastnet Pre-Med Questionnaire Has anyone (doctor, dentist) told you that you need to pre-medicate before dental treatment (for e.g. due to heart murmur, hip or joint replacement?) YES NO IfYES- reason for pre-med Are you taking a daily dosage ofaspirin? Dosage Dr.'s Name Dr.'s Address Dr.'s TeM Print name ofpatient Signature (patient, parent or guardian) Date
6 RECORDS RELEASE FORM Date To (Previous Office/Doctor name) Address City State Zip Phone # Fax# I authorize the release ofmy dental records and medical records relevant to dental treatment, or copies ofsuch, and request that they are transferred to: Pleasant Dental Center George A. Ezzi, D.M.D. Christa Rizkallah, D.M.D I26A Pleasant ValleySt., Suite 4 - Mailmen MA 01X44 Telephone: (978) Fax: (978) Entail: pleascnittlentalcenter@comcast.net Please list any other family members: NAME Relationship Print name ofpatient and SS# Signature (patient, parent or guardian)
7 GEORGE ABOU-EZZI, D.M.D. CHRISTA RIZKALLAH, D.M.D. Pleasant Cental (?mter 126A Pleasant QPallep Qfyrwt, O&uilo 4 omethum, OMA 0/844 letaa (978) (jfm (978) GLwa/l plmsaitldcnkdcciilor&comcasl nel Written Financial Policy Thank You for choosing Pleasant Dental Center. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options You can choose from: Cash, Check, Visa, MasterCard or American Express Wc offer 10% courtesy accounting adjustment to patients who pay in full for their treatment with cash or check. NO INTEREST Payment Plans through 3rd party. - Allow you to pay over time with NO INTEREST Convenient, low monthly payment plans also available No annual fees or pre-payment penalties Please note: Pleasant Dental Center requires payment prior to the beginning of your treatment unless other arrangements have been made with our financial department. For larger, more comprehensive treatment plans of $500 or more, a 10% deposit is required to secure your initial treatment appointment. For patients with dental insurance, as a courtesy to you, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. A fee of S50 is charged for patients who miss or cancel and scheduled appointment without 24-hour notice. Our office reserves the right to discharge a patient who accrues two or more missed appointments. Pleasant Dental Center charges $25 for returned checks and a 10% finance charge on any unpaid balance. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Signature (patient, parent or guardian) Print name of Patient Date
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
PATIENT REGISTRATION
PATIENT REGISTRATION Name: Date: First MI Last Preferred Name: RESPONSIBLE PARTY: (if someone other than the patient) First Name: Last Name: Middle Initial: Address: City: State: Zip: Home #: Work #: Ext:
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 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
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 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
Patient Information. Dental Insurance. Phone Numbers
Our goal is to provide you with the safest, most comfortable experience a dental office can provide. If you have any questions please do not hesitate to call us. Patient Information Date: SS/Patient ID:
David P. Price, DDS, PA Family Dentistry
PATIENT NAME David P. Price, DDS, PA Family Dentistry Welcome to our Practice! We are glad you are here! Please complete the following forms. PATIENT INFORMATION PATIENT'S SOCIAL SECURITY NUMBER_ OCCUPATION
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. 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
Dental History. Medical History
DENTAL & MEDICAL HISTORY Dental History Reasons for today s visit: Date of last dental care: Date of last dental xrays? Former Dentist: Address: Phone: Would you like for your records to be sent to our
Patient: Last name: First Name: DOB: Social Security Number: Relationship Status: Sex: F/M
PATIENT INFORMATION Patient: Last name: First Name: Relationship Status: Sex: F/M Cell Phone: Home Phone: Employer Name: E-mail: How did you hear about us? Parent/Guardian Information (REQUIRED IF PATIENT
PERSONAL HISTORY. Spouse s Name:
PERSONAL HISTORY Date: Patient Name: Address: Zip Code: Sex: Marital Status (circle one): S M D W Sep Spouse s Name: Date of Birth: / / Social Security Number: - - Employer: Home Phone: Cellular Phone:
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
Preferred Name: First Name: Last Name: Middle Initial: Work Phone: Ext: Cellular:
TIME PATIENT REGISTRATION DATE ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party ( if someone other than the patient ) Last Name: Preferred Name: Middle Initial: First
L. JASON PAYNE, D.M.D., P.C.
L. JASON PAYNE, D.M.D., P.C. PATIENT REGISTRATION First Name: Last Name: Middle Initial: Patient Is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient)
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 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
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:
Todd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics
Todd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics 3048 E Baseline Rd. Ste. 112 Mesa, Arizona 85234 Telephone: 480-558-4500 Fax: 480-827-9703 PATIENT INFORMATION Today's Date Name Social Security
Patient Registration
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: Patient is: Policy Holder Responsible Party Address: City State/Zip Home Phone: Cell Phone: Work Phone: Sex: Male Female Marital
Macon County Health Department Dental Clinic
Macon County Health Department Dental Clinic PATIENT REGISTRATION ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name:
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:
PATIENT FIRST NAME LAST NAME MI FIRST NAME LAST NAME MI ADDRESS CITY, STATE, ZIP HOME PHONE WORK # CELL# BIRTH DATE SOC SEC # - - DRIVERS LIC #
PATIENT REGISTRATION PATIENT FIRST NAME LAST NAME MI PREFERRED NAME PATIENT IS: POLICY HOLDER RESPONSIBLE PARTY RESPONSIBILE PARTY (If someone other than the patient) FIRST NAME LAST NAME MI ADDRESS CITY,
Welcomes You! Patient Information. Name: Preferred name: Male Female (Last) (First) (Mi) Home Address: (Street) (City) (State) (Zip)
Welcomes You! Patient Information Today s Date: E-mail Address: I would like to receive correspondence via: e-mail text phone Name: Preferred name: Male Female (Last) (First) (Mi) Birthdate: / / Age: Social
Patient Registration
Patient Registration Patient s Name: Date of Birth: Mailing Address: Social Security #:_ Primary Phone #: Secondary Phone #: Employer: Work Phone: _ Emergency Contact: Emergency Contact Phone #: Person
WELCOME TO INFINITY DENTAL EXCELLENCE
WELCOME TO INFINITY DENTAL EXCELLENCE Today s : Email Address: Name: I prefer to be called: o Male o Female Last First MI Mr. Mrs. Ms. Dr. Birthdate: / / Age: Social Security #: o Single o Married o Divorced
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
Responsible Party (if someone other than the patient)
PATIENT REGISTRATION ID First Name Last Name Chart ID Middle Initial Patient is Policy Holder Responsible Party Preferred Name Responsible Party (if someone other than the patient) First Name Last Name
Patient registration. MyIdealDental.com. Primary insurance information. Secondary insurance information
Patient registration Patient ID Chart ID Medicaid ID Employer ID First Name Last Name Member ID Carrier ID Preferred Name Middle Initial Patient is: Primary policy holder Responsible Party is: Primary
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
FINANCIAL POLICY. Policy Regarding Minor Children
FINANCIAL POLICY We are committed to providing you and your family with the best possible care. In order to achieve these goals, we need your assistance and your understanding of our policy regarding payment
New Patient Paperwork
New Patient Paperwork Patient Information: Patient Name: DOB: Home Address: City: State: Zip Code: Home #: Cell #: E-Mail: @. Would you like to receive text messages and/or emails as appointment reminders?
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
Welcome to Metropolitan Dental Care
Welcome to Metropolitan Dental Care Personal Information Date_ First Name Last NameMiddle Initial Preferred Name Address City, State, Zip Home Phone Work Phone_Cell Phone Male Female Minor Single Married
Patient Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist.
Patient Profile First Name Last Name Pref. Name Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Emergency
MartinDental. Welcome to
Welcome to MartinDental We want you to have the most relaxing and comfortable experience possible with us. Help us get to know you by answering the following questions. Thank you! When I think about coming
Please do not hesitate to call us if we can answer any questions about these forms or your first visit with us.
Welcome to our Practice! We are delighted that you have selected our office for your dental care. To assist us in providing you with excellent service, please take a few minutes to print the enclosed forms
PATIENT REGISTRATION
Date: How did you hear about us? Name of previous dentist: PATIENT REGISTRATION PATIENT INFORMATION First Name: Last Name: Middle Initial Preferred Name: Birth Date: / / Age: Male Female Soc Sec: - - Address:
HARTSELLE FAMILY DENTISTRY, LLC PATIENT REGISTRATION
HARTSELLE FAMILY DENTISTRY, LLC 256-773-0800 PATIENT REGISTRATION Maggie McKelvey, D.M.D Ashley Holladay, D.M.D Patient Information First Name: Last Name: Address: Address 2: City: State: Zip Code: Home
HARTSELLE FAMILY DENTISTRY, LLC PATIENT REGISTRATION
HARTSELLE FAMILY DENTISTRY, LLC 256-773-0800 PATIENT REGISTRATION Maggie McKelvey, D.M.D Ashley Holladay, D.M.D Patient Information First Name: Preferred: Last Name: Address: Address 2: 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
What to expect at your first visit
What to expect at your first visit Welcome'to'Grin.' To'save'you'time'at'your'4irst'visit,''complete'the'following'forms'before'you'arrive'for'your'appointment.''' ' ' ' The'typical'initial'visit'consists'of'the'following:'
Patient Registration
Patient Registration Patient Name: Preferred Name:_ Birth :_ Social Security #:_ Address: Street Unit # (if applicable) City State Zip Code Home Phone #: Cell Phone #: Email: Preferred method of contact?
Address City State Zip
6500 N Mopac Expy #2204, Austin, TX 78731 (512) 458-3111 Patient Registration Today s Date Patient Name Driver s License How did you hear about Austin Smiles? Is this visit related to a Routine Exam &
Street Address City State Zip. Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor Separated Divorced
PATIENT REGISTRATION AND MEDICAL HISTORY First Name: Last Name: Middle Initial: Preferred Name: Street Address City State Zip Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor
Firewheel Smiles corn
Firewheel Smiles corn Patient Name: 4502 River Oaks Pkwy Suite 200, Garland, TX 75044 (214) 703-5490 Registration and Health History Patient Information Today's Reason for this visit: Patient's Name: DOB:
Patient Profile. Appointment Preference. Referral Profile. Insurance Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec.
Patient Profile First Name Last Name Pref. Name of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Phone # Emergency
Patient Registration Montgomery Dental Arts
Patient Registration Montgomery Dental Arts Patient s First Name: Middle: Last: Preferred Name: of Birth: Patient is covered by dental insurance: / Patient is the person responsible for payment: / Address:
Kathryn E. Boehly, DMD & Associates 6290 Linton Boulevard, Building IV, Suite 202, Delray Beach, Florida 33484
Kathryn E. Boehly, DMD & Associates 6290 Linton Boulevard, Building IV, Suite 202, Delray Beach, Florida 33484 Phone: (561) 381-4744 Fax: (561) 381-4743 reception@drboehly.com www.drkathrynboehly.com PATIENT
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
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
9521 US Hwy 290 West, Suite 103 Austin, TX (512) PATIENT INFORMATION
9521 US Hwy 290 West, Suite 103 Austin, TX 78737 (512) 888-9453 PATIENT INFORMATION Please Circle Title: Dr. Mr. Mrs. Miss Name: First M Last I prefer to be called: Male Female Birthdate: Age: _ SSN #
tvcle EXPRESSIONS Phone: (727) 78-SMILE Looking forward to seeing you!
I DR. LYNDSAY H. MCCASLIN Cosmetic & Family Dentistry Phone: (727) 78-SMILE 727-787-6453 oo so U. af c =3 < 2 Thank you for choosing our dental practice. We look forward to meeting you, and giving you
White Rock Dental. Periodontal Treatment (Deep Clean) Bleeding Gums. Sensitivity of your teeth to heat or cold Clicking/Popping jaw joints
Patient Information: (All Fields Required) Date: Legal First Name: Last: MI: Preferred Name: Date of birth: SSN: Address: Apt? No Yes: Apt #: City/State: Zip: Email: Home Ph: Cell: Prefer Contact By: Call
PATIENT REGISTRATION
PLEASE PRINT PATIENT REGISTRATION First Name: Last Name: Middle Initial: Preferred Name: Patient is : Responsible Party Policy Holder Patient Information: City, State, Zip: Home Phone: Work Phone: Cell
Patient Registration Form
Patient Registration Form Patient Name: Date of Birth: SS #: Driver s License: Address: City/State/Zip: Name of Insured: Insured SS#: Insured DOB: Relation to Patient: Spouse Parent Other Employer: Position
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
TfeTaCma DentaQ LXJZ Michael DePalma, DDS Errin DePalma, DDS. 500 Franklin Avenue, Unit 3 Berlin, MD , P
Conf i r m appoi nt mentby : Emai l Phone T ex t SMILE SURVEY YES NO Do you like to smile and show your teeth? Are you happy with the way your teeth look? Do you have unsightly crowns or fillings? Are
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
Family Dentistry ANDREW P MINIGH DDS
PATIENT INFORMATION: Family Dentistry ANDREW P MINIGH DDS First Name: Last Name: Middle Initial: Address: City: State/Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security # Driver s
Patient Registration/Financial Policy
Patient Registration/Financial Policy Date: Patient Information First Name: Last Name: Middle Initial: Preferred Name: Parent/Legal Guardian(s) if under the age of 18: Address: City: State: Zip: Home Phone:
Insurance Company: Group No.: Insurance address: City:
Patient Information First Name: Last Name: Middle Initial: Preferred Name: Birth Date: / / Age: Sex: Male Female Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Preferred Phone# for
First Name Last Name Middle Initial. City State ZIP. Birth Date: SS#: Driver s Lic#: State:
DATE PATIENT ACCOUNT NO PatientRegistration PATIENT S FULL NAME Policy Holder Responsible Party RESPONSIBLE PARTY (if someone other than the patient) First Name Last Name Middle Initial City State ZIP
PARENT/GUARDIAN INFORMATION
Ahmadi & Alvand, DDS, PA General, Cosmetic and Implant Dentistry PATIENT INFORMATION Full Name Preferred Name Address City State Zip code Home Phone Number Work Cell phone Language Sex Marital Status:
Today's Date: (MM/DD/YEAR) / /20
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
REGISTRATION FORM HISTORY Patient Information
REGISTRATION FORM HISTORY Patient Information Name: of Birth SS # Home phone # ( ) Cell phone # ( ) Address Apt. # City State Zip Driver s License # State Email Address: Check Appropriate Box: Minor Single
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
Jennifer Q. Le, DMD, D-ABDSM, CPCC, ACC Diplomate of American Board of Dental Sleep Medicine. Dental Patient Registration
Dental Patient Registration Patient Information First Name: Middle: Last: How did you hear about us? Preferred Name: Address: City, State, Zip: Home Phone: Work Phone: Ext: Cellular: Email address: By
Referred By Phone. Pharmacy Name, Location & Phone #
3150 E. 41 st St., Suite 131, Wellington Square Building Tulsa, Ok 74105 (918) 749-1639 Fax (918) 749-0416 info@midtownsmilestulsa.com Patient Information Patient Name Address City State Zip Date of Birth
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Name: Last Name: Middle Initial: Preferred Name: Referred By: Patient is: Responsible Party Policy Holder Patient Information: Address: City, State, Zip: Home Phone: Work Phone:
Patient Information Sheet Date: Chart ID: Whom may we thank for referring you?
Patient Information Sheet Date: Chart ID: Whom may we thank for referring you? First Name: Driver License: Last Name: SSN: Middle Initial: Preferred Name: E-mail: Gender: o Male o Female Please circle:
Primary Insurance. Insurance Group # Insurance Phone # Please present your Insurance Card and Driver's License to the receptionist to be photocopied*
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
Drs. Helsby and McMann 2100 AlomaAve., Suite 200 Winter Park, Fl
2100 AlomaAve., Suite 200 Winter Park, Fl. 32792 PATIENT REGISTRATION First Name: Preferred Name: Birth : City, State, Zip: Home Phone: _ Drivers License # Last Name: Middle Initial Patient is: Policyholder
Board Certified in Periodontics Board Certified in Oral Medicine Fellowship in the Academy ofgeneral Dentistry. Social Security
Implants (\J PERIODONTICS Oral Medicine ~ George Quintero, D.D.S., P.C. Board Certified in Periodontics Board Certified in Oral Medicine Fellowship in the Academy ofgeneral Dentistry ~ Patient Information
Joplin Periodontics & Implant Dentistry Humaira Y. Habib, D.D.S.
Today s Date: Preferred Name: Patient Information Last Name: First: Middle: Mr. Mrs. Birth Date: Miss. Ms. / / Is that your legal name? If not, what is your legal name? Age: Sex: Male or Female Address:
Welcome. Firas Salhi, DDS Terrylynn Tennant, DMD, AADSM
Welcome Firas Salhi, DDS Terrylynn Tennant, DMD, AADSM A very warm welcome to you! The entire team would like to thank you for selecting our office to care for your dental needs. Our goals are to provide
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)
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,
Meds Yes No. Joshua F. Maxwell, D.D.S Dallas Pkwy, #100 Frisco TX First Name Middle Initial. Address City State/Zip
Allergies Yes No Meds Yes No Premed Yes No Preferred Pharmacy Info: Joshua F. Maxwell, D.D.S. 11955 Dallas Pkwy, #100 Frisco TX 75033 469-633-0550 Patient information First Name Middle Initial Last Name
WELCOME TO SMILE BY DESIGN
WELCOME TO SMILE BY DESIGN Please tell us about yourself Name: Last First MI Title Preferred Name: Male Female Address: City: State: ZIP: SSN: DOB: Home Phone: Work Phone: Cell Phone: Email Address: Employer:
Completed Medical and Dental Health History Form (please be thorough).
NEW PATIENT PAPERWORK CHECKLIST Thank you for taking the time to visit our website and for downloading your new patient paperwork. In order for your appointment to begin on time, please review the following
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
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
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:
Fort Wayne Dental Group
Fort Wayne Dental Group 7202 Engle road * Fort Wayne, Indiana 46804 * (260) 432-3459 PATIENT INFORMATION DATE: NAME: Married Single Male Female LAST FIRST M ADDRESS: STREET APT.# CITY STATE ZIP BIRTHDATE:
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
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
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
Registration. Patient Information: Patient Responsibility:
Registration Patient Information: David A Carbonaro, D.D.S. 6800 Pittsford-Palmyra Road Building 400, Suite 405 Fairport, New York 14450 (585) 223-6040 Fax (585) 223-3266 Diplomate of The American Board
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:
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:
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
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
Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:
Today s : Name: Nickname: Male Female Birthdate: / / SS#: Email: Home #: Work #: Cell #: Best Time to Contact You: Preferred Method of Contact: Please choose all that apply. Home Work Cell Text Email Address:
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
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
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 any questions we ll be glad to help you. We look forward to
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
New Patient Registration
New Patient Registration 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 any questions, we will be glad to assist you.