Philip N. Hodge, DDS, PS
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- Audra Parks
- 5 years ago
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1 th Avenue SE, Ste. 4 Renton, WA (253) tel (253) fax Welcome to our office. We appreciate the confidence you place with us to provide dental service. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any uestions, don t hesitate to ask. PATIENT S NAME Preferred Sex F M Married Single Mailing Address City/State Zip Home Phone Cell of Spouse Cell Work Phone Ext # Soc. Security No. Occupation Work Phone Ext # s of children living at home: Soc. Security No. Patient Occupation How can we best reach you? Cell Pager Work Home Time of Day AM PM Previous Dentist s Telephone # Whom may we thank for referring you? PRIMARY DENTAL INSURANCE Employee SECONDARY DENTAL INSURANCE Employee Insurance Co. Group# Insurance Co. Group# Insurance ID No. Insurance ID No. Person responsible for payment: IN CASE OF EMERGENCY, WHOM MAY WE CONTACT? Hm Wk Relationship to Patient Physician s Form NP AD INFO 050/18/17
2 Patient s Please mark any that apply: Are you apprehensive about dental treatment? If so, what is your biggest concern? Have you had problems with previous dental treatment? If so, please describe. Do you gag easily? Do your gums bleed or hurt when you brush or floss? How often do you brush? How often do you floss? DENTAL HEALTH HISTORY MEDICAL HEALTH HISTORY Do you have, or have you had, any of the following: Heart Problems Chest pain Shortness of breath Blood pressure problem Heart murmur Heart Attack Heart valve problem Taking heart medication Rheumatic fever Intestinal Problems Ulcers Weight gain or loss Kidney or bladder problems Bone or Joint Problems Arthritis Back or neck pain Joint replacement (e.g, total hip, pins, or implants) Pacemaker Fainting Spells, Seizures, or Epilepsy Artificial heart valve Stroke(s) Blood Problems Freuent or severe headaches Abnormal bleeding Thyroid problems Blood disease (anemia) Persistent cough or swollen glands Allergy Problems Premedications reuired by physician Hay fever Cancer/Tumor Sinus problems Tuberculosis or other respiratory disease Skin rashes Do you smoke? Taking allergy medication If so, how much? Asthma Are you allergic, or have you reacted adversely, to any of the following? Local anesthetics ( Novocaine ) Penicillin or other antibiotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin, Acetaminophen, or Ibuprofen Codeine, Demerol, or other narcotics Reaction to metals Latex or rubber dam Notes: Do you clench or grind your teeth while awake / asleep? Do you have clicking or popping when opening or closing? Do you have pain of joint, ear, or side of face? Do you feel pain when your teeth come in contact with: Hot foods or liuids? Cold foods or liuids? Sweets? Do you experience chewing sensitivity? Does food catch between your teeth? Women Are you taking contraceptives or other hormones? Are you pregnant? If so, expected delivery date: Are you nursing? Current list of medications & Dosage: Diabetes Urinate more than 6 times a day Thirsty or mouth is dry much of the time Family history of diabetes Hepatitis, jaundice, or liver trouble Herpes or other STD HIV-positive/AIDS Glaucoma Do you wear contact lenses? History of head injury? Epilepsy or other neurological disease? History of alcohol or drug abuse? Do you have any disease, condition, or problem not listed previously that you feel we should know about? If so, please describe During the past 12 months, have you taken any of the following? Antibiotics or sulfa drugs Anticoagulants (e.g., Coumadin) High blood pressure medicine Osteoporosis medication Tranuilizers Insulin, Orinase, or similar drug Aspirin (daily) Digitalis or drugs for heart trouble Nitroglycerin Cortisone (steroids) Natural remedies Nonprescription drug/supplements I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize Dr. Hodge and/or dental staff to perform all necessary dental services that I may need. I understand that I am responsible for payment of services rendered and also responsible for paying any unpaid portion that my insurance does not cover. Signature Notes: Form AD HH 11/23/2009
3 Comments:
4 The Fine Art of Dentistry - Patient Financial Policy - In the interest of good communication and our continued commitment to provide the highest uality of dental care available to all of our patients, we have established a Patient Financial Policy. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your care. We are committed to support you in understanding your dental health, and will always present you with the best dental solution possible to treat your personal situation. To make these services comfortably affordable we are pleased to offer you the following payment options. Please select one. 1. Cash, Check, Debit 2. Visa, MasterCard, Discover, American Express 3. Payment Plan We will, as a courtesy, process your insurance benefits in our office. Specific uestions regarding your insurance benefits must be addressed to your insurance carrier. I agree that I am fully responsible for the total payment of all procedures performed in this office this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that any estimated portion, not covered by insurance, is due at time of service for all services rendered. I understand that all services are due to be paid within ninety (90) days of date of service, regardless of whether or not my insurance benefits have been received. One percent (1%) per month interest, twelve percent (12) per year will be charged on accounts 90 days from treatment date. I also understand that should credit be extended to me by this dental office, a credit check will be made through TRW or other credit services and I authorize release of all financial data. Please make your uestions and concerns known to our Accounts Manager who is happy to discuss this policy and ensure that you have an outstanding experience. Signature (responsible party) th Avenue SE, Suite 4 ~ Renton, WA ~ (253) fax (253) info@drphilhodge.com ~
5 ACKNOWLEDGEMENT OF PRIVACY PRACTICES th Ave. SE Suite 4 Renton, WA My Signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly Obtain payment from third-party payers for my health care services Conduct normal health care operations such as uality assessment and improvement activities I have been informed of my dental provider s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of Notice of Privacy Practices. I understand that I may reuest in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that your are not reuired to agree to my reuested restrictions, but if you do agree then your are bound to abide by such restrictions. Patient : : Signature: Relationship to Patient: Dependent family members also covered by this acknowledgement: For Office Use Only: We were unable to obtain the patient s written acknowledgement of our Notice of Privacy Practices due to the following reason: The patient refused to sign Communication barriers Emergency situation
Patient Registration. Name: Last First Middle Nickname. Street Address: / Street City State Zip. Mailing Address: / Street City State Zip
Patient Registration Name: Last First Middle Nickname Street Address: / Street City State Zip Mailing Address: / Street City State Zip Birthdate: / / SSN: - - Male Female Month Day Year Home phone: Cell:
Herbert E. Todd, DDf 'LLC Famil Dentistr
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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:
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)
PERSONAL INFORMATION
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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.
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PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
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Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc. Birth Date: Social Security # Previous Visit Date
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Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
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Patient Information & Health History Page 1. Date:
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Welcome. Name Perferred name Last First MI Mr Mrs Ms Dr Birthdate Social Security Number Single Married Divorced Widowed
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Address Who referred you to our practice? relationship
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Michael Mabry, DDS, MAGD
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REGISTRATION FORM Section I: Patient Information. Date: Name: SSN: - - Date of Birth:
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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
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:
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 AND PHONE NUMBER OF PHARMACY:
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 E-Mail Birth Date
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
X X Capistrano Children s Dentistry Patient Information Adult Form
X X Capistrano Children s Dentistry Patient Information Adult Form Name: Birthdate: Age: Home Address: Sex: Male Female Occupation: Cell Phone: ( ) - Social Security #: Home Phone: ( ) - Medical Doctor:
Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient
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
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
Patient's name Dr Mr Mrs Ms Miss Preferred name Birth date Social Security # Home phone
Welcome to our practice! We thank you for choosing our team to treat you and your family. The information on this form is important to your health and dental treatment. PATIENT INFORMATION TODAY'S DATE:
Medical Health History
Thank you for choosing our office to assist you with your dental needs. Please fill out the informa on and don t forget to provide your signature at the end. Pa ent s Name: Date of Birth: Sex: If minor,
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:
LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas
LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS Patient Information Patient Name: Date: Last First Mi Preferred Gender(M/F): Marital Status: Birth Date: Social Security # Driver s License#: E-Mail Address: State
Payment Is Expected At Time Of Each Visit
2107 West Pacific Avenue Spokane, WA 99201 Ph 509-838-3544 Fax 509-455-7507 www.luchinidds.com ank you for choosing our o ce. In order to serve you properly, please answer all questions on BOTH sides,