Permission Letter. Patient Name(s):

Talia Pike DMD Patient Information

Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Email Address Parent Name

2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)

2460 India Hook Road, Suite 106 Rock Hill, SC 29732 E-mail: drj@rockhillkids.com Tel: (803) 327-3327 Fax: (803) 334-3474 Welcome to our practice! Please carefully complete this form so that we may better

Authorization to Release Health Information

Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity)

Acknowledgement of Privacy Practices

Rev 08/16 Acknowledgement of Privacy Practices My signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability &

Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other

PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:

CONSENT TO PROCEED. Patient Name: (Patient, legal guardian or authorized agent of patient)

CONSENT TO PROCEED I authorize Dr. Tyson Pickett and/or such associates or assistants as s/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health

Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:

Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information

PEDIATRIC PATIENT INFORMATION

PEDIATRIC PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. LAST

Patient Safety and Privacy. Appointment Policy

Patient Safety and Privacy For your comfort one adult is welcome, but not required to accompany your child to the treatment areas. We do encourage self independence to help promote the growth and development

Past Medical History

Past Medical History Patient Name Age: Sex: M or F Allergies:_ of Birth Current Medicines: If Newborn: Was baby born in a Hospital: Y N If Yes what Hospital: Medical History BIRTH HISTORY (Please list

Talia Pike DMD Patient Information

Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Email Address Parent Name

FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.

FINANCIAL AGREEMENT- PAYMENT IS REQUIRED FOR ALL DENTAL SERVICES AT THE TIME TREATMENT IS RENDERED. We accept Visa, MasterCard, Discover, American Express, Care Credit, Cash or Check. INSURANCE FILING-

Singh Family Dental Dr. P. Singh, PLLC

Singh Family Dental Dr. P. Singh, PLLC 25 Country Club Road, #301 Gilford, NH 03249 (603)524-7455 251 Mayhew Turnpike Plymouth, NH 03264 (603)536-7600 260 Route 16B Center Ossipee, NH 03814 (603)539-4995

PPO/HMO/SELF-PAY PATIENT INFORMATION ACKNOWLEDGMENT FORM PATIENT RIGHTS AND ACKNOWLEDGMENT FORM

PPO/HMO/SELF-PAY Dear New Patient: We know your time is valuable and we strive hard to begin and end our treatment sessions timely. As a new patient we have several forms for you to fill out. If you would

NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK

PATIENT INFORMATION NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - ADDRESS CITY STATE ZIP HOME PHONE CELL OTHER EMAIL How did you hear about our office? HEAD OF HOUSEHOLD NAME: LAST FIRST MI

*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*

DR. MILES MAZZAWI DR. ANTHEA DREW MAZZAWI DR. NIRALI PROCTER 205 Waleska Rd. Suite 2-B Canton, GA 30114 (770) 479-1717 Today s Date: / / We are so pleased to welcome you and your child to our practice!

Today s date: PATIENT INFORMATION. Address:

Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Please send appointment reminders to: Mobile phone #: Email Address: Mr. Mrs. Registration and Medical History Marital status Single

Financial and Insurance Agreement

Financial and Insurance Agreement I understand that payment for my dental treatment is due in full at the time services are rendered. The office accepts cash, check, Visa, Master Card, Discover. A service

All About Kids Pediatric Dentistry

Dr. Courtney Wilson & Dr. Melanie Nesbitt Patient Registration Date: Patient s Name Nickname Birth date Age Sex Patient s Address Contact Phone # street city state zip Father s Name DOB Mother s Name DOB

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment

PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our

Family address preferred for patient portal access:

: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB

Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip:

PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip: Emergency Contact: Phone: Alt: Email: Primary Care PHYSICIAN Name:

Trinity Family Physicians

Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor

Patient Registration

Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number:

Pediatric Dentistry Health History

Pediatric Dentistry Health History Child s Full Name: Nickname: Sex: M F Date of Birth: / / Age: SSN # Best Phone # ( ) Grade: School: Name(s) and ages of other children in family: Name(s) of your other

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino

HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance

HEALTH HISTORY FORM 4 How Did You Hear About Us? 5 Who is Accompanying the Child Today? Name Today s 1 2 3 Tell Us About Your Child Patient s Full Name Preferred Name Male Female Siblings We Treat Patient

Welcome to a Brighter Morgantown!

Welcome to a Brighter Morgantown! New Patient Information Payment Options E X C E L L E N C E I N D E N T I S T R Y S I N C E 1 9 2 7 Welcome to a Brighter Morgantown! Morgantown Dental Group would

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:

Tree House Pediatrics, PLLC

Tree House Pediatrics, PLLC Office Policies Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policies allows for a good flow of communication

GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 GETTING TO KNOW YOU 1. How important is it for you to keep your teeth healthy for a lifetime? 2. If you could change one

GENTLE DENTAL CARE OF ROCHESTER PC

Patient Rules GENTLE DENTAL CARE OF ROCHESTER PC 1. All Forms and letters require 1 week to complete. This includes school forms, dental records, copy of x-rays, prior authorization request, referrals,

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 DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:

TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:

Date How did you hear about Shine? P A T I E NT I N F O R M A T I O N

How did you hear about Shine? P A T I E NT I N F O R M A T I O N 1. Patient's Name of Birth / / Gender: Male Female 2. Patient's Name of Birth / / Gender: Male Female 3. Patient's Name of Birth / / Gender:

PATIENT REGISTRATION INFORMATION FOR MINORS

Today s Date: / / 620 Dr. Calvin Jones Highway, Suite 212 Please fill out and sign all registration paperwork attached. This will help us better serve you during your time at our clinic. PATIENT REGISTRATION

Mother s Name: Birth date: SSN: Home Address: City State Zip Home Phone# Work # Cell # Address Employer

Kid City Smiles Mary Beth Tabor, DDS 107 Maple Row Blvd Hendersonville, TN 37075 615.822.5588 615.822.3206fax Child s Name Today s Date Home Address City_State Zip Home Phone# Work # Cell # Date of Birth

CHILD S REGISTRATION & HISTORY

SIMON P. MORRIS, D.D.S. MAI DINH D.D.S., M.S. CHILD S REGISTRATION & HISTORY Child s name FIRST MIDDLE LAST Nickname Date of birth Age Male Female Child s interests Pets Other children in family who are

Drs. Birdwell and Guffey. Comprehensive Family Dentistry. Dr. Vicki Davis Guffey, DDS 529 E Gov John Sevier Highway Phone (865)

Drs. Birdwell and Guffey Comprehensive Family Dentistry Dr. Vicki Davis Guffey, DDS 529 E Gov John Sevier Highway Phone (865) 573-9629 Dr. Chris R. Birdwell, DDS Knoxville, TN 37920 Fax (865) 577-3966

CONSENT TO DENTAL TREATMENT

DENTIST: Matthew Kelley DDS CONSENT TO DENTAL TREATMENT PATIENT: 1. I request and authorize the above listed provider of service, and/or such other persons as he may appoint to perform or assist in the

BROKEN APPOINTMENT/LATE PATIENT POLICY

BROKEN APPOINTMENT/LATE PATIENT POLICY Reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure

425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female

425 North Wendover Road Charlotte, NC 28211 PATIENT INFORMATION: Patient s Legal Name: Nickname: Birthdate: Social Security #: Male Female Status: Minor (under 18) Single Married Separated Divorced Widowed

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH

Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:

Patient Information: Name: Date: Last, First MI (Preferred Name) Social Security #: Birth date: / / Gender: Family Status: Address: City/State/Zip: Phone (Home): (Cell): (Other): Employer Name: Work Phone:

PLEASE PRINT & FILL OUT COMPLETELY PATIENT/PARENT INFORMATION ADDRESS:

2150 S. Eastern Avenue 7180 Cascade Valley Ct. #180 Las Vegas, Nevada 89104 Las Vegas, Nevada 89128 Phone (702) 641-2150 Phone (702) 641-2150 Fax (702) 641-8667 Fax (702) 228-1043 PLEASE PRINT & FILL OUT

Consent for Services and Financial Policy

Consent for Services and Financial Policy As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for

4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone

Dr. Jeffrey D. Singer Specialty Permit # 5722 1001 Laurel Oak Road Suite C-2 Voorhees, NJ 08043 Phone: (856) 783 3515 Fax: (856) 783 3517 www.abcchildrensdentist.com PATIENT REGISTRATION 1. Tell Us About

WELCOME. Dr. Susan Bracker 1 Saredon Place, Suite 100 Rochester, NY CHILDS NAME: CHILDS HOME ADDRESS: NAME: RELATION:

TELL US ABOUT YOUR CHILD CHILDS NAME: CHILDS HOME ADDRESS: WELCOME Dr. Susan Bracker 1 Saredon Place, Suite 100 Rochester, NY 14606 585-225-5600 EMAIL: CHILDS DOB: AGE: M/F NICKNAME SCHOOL: CHILDS PHONE

Dental Benefits (Insurance) Guide

PATIENT RESOURCES Dental Benefits (Insurance) Guide A General Guide To Help You Understand The Basics Of Your Dental Insurance. By Dr. Matthew T. Ertl Laurelwood Family Dentistry Asheville, North Carolina

Welcome! Warren Parkway Suite 306 Frisco, TX PlastiksForKids.com. Please remember to bring: New Patient Paperwork

Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. All appointments are on Monday afternoons. Dr. Stiles operates at the Pediatric Surgery Center. Plastiks

Pediatric Dentistry: JEROME S. CASPER, D.M.D. & ASSOCIATES General Dentistry (Olney): RIZWAN AHMAD, D.D.S.

Pediatric Dentistry: JEROME S. CASPER, D.M.D. & ASSOCIATES General Dentistry (Olney): RIZWAN AHMAD, D.D.S. CHILDRENS DENTAL OFFICE FINANCIAL POLICY We would like to welcome you to our office and thank

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose

Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:

First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:

Patient Information. Responsible Party. Notify in case of emergency?

We are pleased to welcome you and your child 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

Patient and Contact Information

Patient and Contact Information PATIENT INFORMATION First Name M F Middle Name Age Last Name D.O.B. Address City Postal Code Home Phone ( ) What days and times are best to contact you? Business Phone (

Referred By: Can we contact?

Patient: Date: Address: City ST Zipcode HPhone: WPhone: Cphone Can we leave message? Married Single Employed Student Full/Partime DOB: Social Security: Emergency Contact: phone# Is your condition related

Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.

Today s Date Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.H NAME OF PATIENT (CHILD) DOB SSN of child SEX

Worcester Kids Dentist 41 Lancaster Street, Worcester, MA Child Health History. Name of Child

, Child Health History Name of Child DOB 1) Were there any difficulties during the pregnancy, delivery or first year of life? Yes No 2) Is a physician treating your child now for a specific illness? Yes

PATIENT APPLICATION FORM

PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very

Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :

Patient Information: Fairview Dental Date: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: : Email: Check one : Child Single Married Divorced Widowed

PATIENT REGISTRATION

Dr. Jaish J. Markos State License #053850 50 Dayton Lane Ste #103 Peekskill, NY 10566 Phone: (914) 402 6980 www.gckidsdmd.com PATIENT REGISTRATION Date 1. Tell Us About Your Child Child s First Name Middle

Sparta Dental Center Office Policy Statement

Sparta Dental Center Office Policy Statement Our practice believes in the theories of modern dental care. Through proper preventive care and regular checkups, we believe that it is highly likely that most

2014 Established Patient Registration Welcome to the New Year! We ask that all of our patients provide us with updated information, such as phone number, address, insurance, etc, as well as sign an updated

SPOKANE PEDIATRIC DENTISTRY PATIENT REGISTRATION

SPOKANE PEDIATRIC DENTISTRY PATIENT REGISTRATION Spokane Pediatric Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,

Today s Date / / Male Female. Child s Name Preferred Name. Child s Address City Zip. How were you referred to our office?

Today s Date / / Male Female Child s Name Preferred Name Child s Birthday / / Cell # ( ) - Home # ( ) - Child s Address City Zip How were you referred to our office? Who is accompanying this child today?

PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip

Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.

Welcome to Pediatric Therapy Center, PC!

Welcome to Pediatric Therapy Center, PC! We appreciate the opportunity to work with you and your child. Please read through and complete all paperwork before your arrival. We ask that you please arrive

NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service.

6101 Redwood Square Center Suite 300 Centreville, VA 20121 5047 Backlick Road Suite A & B Annandale, VA 22003 Health History Form Today s Date: NOTE: The parent or Guardian who accompanies the child is

Tulsa Pediatric Urgent Care Clinic Patient Information Sheet

Tulsa Pediatric Urgent Care Clinic Patient Information Sheet Please read carefully and fill out form completely Date: Patient (Last) (First) (MI) Date of Birth: Male or Female Home/ Mailing Address: (City)

Medical History. Authorization to Treat. Financial Policy. Notice of Privacy Practice

Authorization to Treat Financial Policy Medical History Notice of Privacy Practice Authorization to Treat Patient Name I authorize Dr. Gregory C. Thiel to perform a complete dental examination and procure

NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. Insurance Co. Name Name

Health History Form Dr. Lisa LaPresti Today s Date: NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. 1. Tell Us About Your Child 5. Child s Name

Approved September 10, 2010; NEW REVISION Sept 13, 2018

Shorewood-Troy Library Circulation Policy The circulation policies of the Shorewood-Troy Public Library District exist to facilitate community access to the materials and information in the library's collections,

Office Policies. Clinic Timing: Monday to Friday: 8 am to 7 pm

Office Policies Thank you for choosing Progressive Medical Care (PMC) for your healthcare needs. Our mention is to provide you best available care in our resources and knowledge. Please take time to read/understand

Patient Information Form

Patient Information Form Name Birthdate Social Security Number Age Address Occupation Phone Number Alt. Phone Number Email Emergency Contact & Phone Number How Did You Hear About Us What Are You Coming

Arthritis & Joint Center of Florida 2328 Medico Lane, Melbourne, Florida fax Financial Policy

Arthritis & Joint Center of Florida 2328 Medico Lane, Melbourne, Florida 32940 321.956.1501 fax 321.956.1502 Financial Policy We are committed to providing the best care at the most reasonable cost. We

Page 1 of 5. Portsmouth Foot and Ankle 14 Manchester Square, Suite 250 Portsmouth, NH Office

Page 1 of 5 Portsmouth Foot and Ankle 14 Manchester Square, Suite 250 Portsmouth, NH 03801 Office 603.431.6070 Welcome! We are happy to have you join our office as a new patient. Thank you for choosing

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different

If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians.

**This form is for your personal use only and is a tool to help you understand your personal health benefits** Call your insurance company (phone number on the back of your insurance card) and ask them

New Patient Registration

New Patient Registration 900 Carillon Parkway, Suite 404 Saint Petersburg, Florida 33716 Ph: 727-572-1333 Fax: 727-572-1331 www.spencerdermatology.com Today s : / / Name: (First) (Middle) (Last) (Suffix)

Welcome to Our Practice

Welcome to Our Practice Greater Baltimore Medical Center (GBMC) welcomes you to our practice. We are dedicated to providing you with the kind of care that we would want for our own loved ones. This Information

Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas Patient Insurance Information

Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312-9310 New Patient Information / Change of Information : New Patient Change

TILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older

Patient Information Form For all Patients 18 years of Age and Older Patient s Information Name: DOB: / / Male Female RACE African-American American Indian/Alaska Native Asian Caucasian Native Hawaiian/Pacific

Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION

Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED

NEW PATIENT INFORMATION FORM

NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring

Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:

Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)

Patient Name: M F LAST FIRST MI. Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( )

Ahwatukee Family Medical Center Patient Information Date: Patient Name: M F LAST FIRST MI Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) EMAIL: Date of Birth: / / SS# Marital Status:

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,

Little Peaches Pediatric Dentistry

Little Peaches Pediatric Dentistry Patient Information Date: Child s name: Nick Name: Date of Birth: Grade: Sex(circle): Male / Female School: Home Address: Street City, State Zip Code Dental Insurance:

New Patient Paperwork Current Insurance Card Valid Driver s License It is also important

Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments

Just for Kids Pediatric Dentistry, Ltd. Patient Information

Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:

ADVANCED THERAPY SOLUTIONS

OFFICE INTAKE A.T.S. must have this page filled out completely by a parent or legal guardian BEFORE any Evaluation can be initiated. PATIENT S NAME : DATE OF BIRTH : SS #: PARENT OR GUARDIAN S NAME: PRIMARY

Policies and information:

Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24

Mary Kate W. DiTursi MD PhD FAAP William A. Grattan MD FAAP Ruth E. Kelleher PNP

Mary Kate W. DiTursi MD PhD FAAP William A. Grattan MD FAAP Ruth E. Kelleher PNP 55 Mohawk Street, Suite 101 Cohoes NY 12047 (518) 233-9500 Fax: (518) 235-4827 www.harmonymillspeds.com Welcome to Harmony

PATIENT INFORMATION. Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: GUARANTOR INFORMATION

PATIENT INFORMATION Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: Home Phone#: Race: Work Phone#: Ethnicity/Nationality: Cell Phone#: Employer:

Welcome to Pediatric Dentistry of Greenville!

Welcome to Pediatric Dentistry of Greenville! Child's Information Child's Name(Last, First, Middle Initial) Child's DOB: / / Child's Age Nickname: ( ) Male ( ) Female School : Grade: Child's Home Phone

PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP

PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

CONROE WOODLANDS GASTROENTEROLOGY DR. STEPHEN M. KELLY 1501 RIVER POINTE DR, STE 240 CONROE TX 77304 129 VISION PARK BLVD, STE 109 SHENANDOAH, TX 77384 Phone: (936) 760.1900 Fax: (936) 441.1907 CONSENT

TODAY S DATE: Name: Birthdate: SSN: _Married _Single _Widowed _Divorced _Separated _Other. Address: Employer: Work Phone:

WELCOME! PATIENT INFORMATION TODAY S DATE: Name: Birthdate: SSN: Home Phone: ( ) Cell: ( ) Married _Single _Widowed _Divorced _Separated _Other Address: Employer: Work Phone: Emergency contact: Phone:(

BIG ROCK GYMNASTICS & DYNAMITE CHEER

BIG ROCK GYMNASTICS & DYNAMITE CHEER Registration Form Please Print Clearly PERSONAL INFORMATION: Mailing Address City St Zip Both Parents E-Mail Address: / Home Phone # Childs Cell # Childs Email Mothers

Child s Name: Last First Middle Preferred Name. Address: Street Apt.# City State Zip. Mother Stepmother Guardian. Name: Employer: Social Security #:

Today s Date We are so pleased to welcome you and your child 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