Jeffrey R. Wert, D.M.D., P.C.
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1 Jeffrey R. Wert, D.M.D., P.C. Patient Registration Form Date: Patient Name: Birthdate: Sex: M F Address: Address: Home Phone: SSN: - - Marital Status: S M D W Cell Phone: Employer: Work Phone: Ext: If student, School: Grade: Spouse/Parent Name: Spouse/Parent Employer: Phone: Ext: Emergency Contact: Phone: Person Responsible For Account Name: Relationship to Patient: Address: Phone: Employer: ID/SSN: Insurance Company: Group : Secondary Ins Co: Policy Holder: Relationship to Pt: ID.: Group : Employer: Dental History Date of last dental visit: Reason for visit: Date of last cleaning: Date of last x-rays: Previous Dentist: Reason for leaving: Have you had any of the following? Loose Teeth Gum Pain/swelling Bleeding when brushing Gum/periodontal disease Periodontal Surgery Oral Surgery Root Canal Treatment Orthodontics Click/noise in jaw Pain in ear or jaw Pain or difficulty chewing Pain opening mouth Treatment for TMJ If child, suck thumb/finger? Injury to head or mouth? Describe: History of Headaches? How frequently? Sensitivity? Cold Hot Sweet Do you have any of the following habits? Grind or clench teeth? Bite nails? Hold objects in mouth? Breathe through mouth? Smoke or chew tobacco? Drink coffee or tea? How often do you brush? Type of toothbrush? If child, does a parent help? Do you floss? If so, how frequently? Fluoride taken in any form? How do you feel about having dental treatment done? Have you ever had an uncomfortable experience? Is there anything else we should be aware of? Signature:
2 TIME 10:43 AM DATE 7/12/2011 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? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? If yes, please explain: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Other If yes, please explain: Metal Latex Sulfa drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes, please explain: Comments: 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 Office Policies and Financial Agreement It is our desire to provide the highest quality of dental care to everyone. The following is a statement of Dr. Jeffrey Wert's dental office s Policies and Financial Agreement. We ask that you please read, agree to, and sign before any treatment is rendered. Regarding Insurance Our goal is to maximize your insurance benefits. It is important to understand that the insurance contract is between the insurance company and you, the insured. Dental insurance was not designed to pay for all dental care. Treatment recommended by Dr. Jeffrey Wert and his associates is never based on what your insurance company will pay. Due to pending claims and patient privacy issues, we do not always know how much an insurance company has already paid to another office or specialist, and the balance remaining on a yearly maximum. Please be prepared to show your insurance card and driver s license at the time of your visit. It is the patient's / guarantor's responsibility to provide any new information regarding insurance. Our office will gladly submit your insurance claim to your insurance carrier, as a courtesy to you. At the time of treatment, the patient / guarantor is responsible for the estimated portion the insurance does not cover. If for some unforeseen reason your insurance carrier has denied or not made payment within 60 days, the patient / guarantor is responsible for the balance in full. (Initial) Payment Options Cash, Check, MasterCard, Visa, Care Credit 3rd Party Financing With prior approval, we are pleased to offer a choice of Interest or Extended Payment Plans to qualified applicants through Care Credit. If you would like to make extended payments for services provided at our office, please ask any of our administrative team for assistance in filling out an application form. (Initial) Additional Charges A fee of $30 will be charged on all returned checks. (Initial) Cancellation Policy 24 Hours tice If you are unable to keep an appointment, we ask that you kindly provide us with a minimum of 24 hours notice. If less than 24 hours notice is given, there will be a $75 broken appointment fee per appointment that is cancelled or missed. Our office does not accept cancellations or changes in appointments via , text, or after hours by voice mail; you must call during our normal business hours. This courtesy on your part will make it possible to give your appointment to another patient who needs to see the dentist or hygienist. (Initial) PRINT PATIENT NAME PATIENT SIGNATURE (PARENT / GUARANTOR signature if patient is a minor) DATE
4 Jeffrey R. Wert, D.M.D., P.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Since Jeffrey R. Wert, D.M.D., P.C. is a HIPAA covered office, our office policy requires you to sign this acknowledgement. If you do not wish to sign this acknowledgement, we are not comfortable seeing you in our office and you will have to locate another dentist. I,, have received a copy of this office s tice of Privacy Practices. A copy of this signed and dated Acknowledgement shall be as effective as the original. My signature will also serve as a Protected Health Information (PHI) document release should I request documents be sent to other attending doctor / treatment facilities in the future. (Signature) (Date) For Office Use Only We attempted to obtain written acknowledgement of receipt of our tice of Privacy Practices, but Acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association. All Rights Reserved
5 Dr. Jeffrey R. Wert & Associates Third Party Authorization Here at our office we are committed to the protection of your personal information. In order to discuss your dental health and/or treatment plans with or release information to third parties, this form must be completed and signed. Please include the names of all individuals that you want to have access to your dental records and/or treatment plans. If you do not want a third party contact(s) on file, please leave this form blank. Name: Phone #: Relationship: Name: Phone #: Relationship: I,, hereby authorize Dr. Wert & Associates to have verbal and/or written communication with the above stated individual(s). This authorization will remain in effect until I submit a written letter or to Dr. Wert & Associates, terminating my consent. Signature: 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 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
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 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:
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: 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
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 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
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 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,
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
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
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
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
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
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
TIME 10:44 AM DATE 7/12/2011 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
WELCOME! Patient Information:
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WELCOME PATIENT INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE
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Patient Registration
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Responsible Party (if someone other than the patient)
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Preferred Name: First Name: Last Name: Middle Initial: Work Phone: Ext: Cellular:
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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
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
PATIENT REGISTRATION
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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
Address City State Zip
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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:
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:
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
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?
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
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REGISTRATION FORM HISTORY Patient Information
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Drs. Helsby and McMann 2100 AlomaAve., Suite 200 Winter Park, Fl
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TfeTaCma DentaQ LXJZ Michael DePalma, DDS Errin DePalma, DDS. 500 Franklin Avenue, Unit 3 Berlin, MD , P
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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
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:
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
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
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?
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
PARENT/GUARDIAN INFORMATION
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New Patient Information
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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:
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
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PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
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PATIENT REGISTRATION. Last Name: Preferred Name: Address 2: Address 2: Work Phone: Ext: Cellular: Insured Birth Date. Ins.
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Patient Information. Patient Name: Preferred Name: Birthdate: SSN: Home Phone: Cell Phone:
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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
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
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
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
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
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
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.
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:
Jackson Center Dental
Patient Information Jackson Center Dental Insurance Information Date: Social Security#: Patient Last Name: Patient First Name: Address: City: State: Zip Code: Sex: o Male o Female Birthday Date: Age: Married
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. 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)
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
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:
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