WELCOME TO RED BANK SMILES! PLEASE, TAKE A MOMENT TO PROVIDE US WITH THE FOLLOWING INFORMATION
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- Edgar Allen
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1 ! WELCOME TO RED BANK SMILES! PLEASE, TAKE A MOMENT TO PROVIDE US WITH THE FOLLOWING INFORMATION I. PATIENT INFORMATION NAME: Name you prefer to be called by, or pronunciation: BIRTHDATE: / / SEX: M / F SS#: II. CONTACT INFORMATION ADDRESS: Preferred method of contact: LAND LINE CELL TEXT If you do not have an answering machine, please provide us a way to leave a message: III. OTHER INFORMATION MARTIAL STATUS: S M D W EMERGENCY CONTACT NAME: RELATIONSHIP: ADDRESS:
2 IV. RESPONSIBLE PARTY SAME AS PATIENT: Y / N If not, NAME: RELATIONSHIP: SS#: BIRTHDATE: / / ADDRESS: Is there a friend or family member who is also a member of our practice? How did you hear about us? V. INSURANCE INFORMATION Primary Carrier INSURANCE COMPANY: GROUP #: POLICY #: If Insured is not Patient, please provide Insured Name: Seondary Carrier INSURANCE COMPANY: GROUP #: POLICY #: If Insured is not Patient, please provide Insured Name: SS#: SS#: BIRTHDATE: / / BIRTHDATE: / / RELATIONSHIP TO PATIENT: EMPLOYER NAME: What is your deductible amount? What is your maximum annual benefit? RELATIONSHIP TO PATIENT: EMPLOYER NAME: What is your deductible amount? What is your maximum annual benefit? As payment is due in full, please provide a payment a Credit Card to retain:
3 VI. EMPLOYER INFORMATION OCCUPATION: EMPLOYER ADDRESS: SIGNATURE: DATE:
4 ! Dental History WHAT CAN WE DO TO MAKE YOUR TIME WITH US A FANTASTIC EXPERIENCE? WHAT WOULD YOU LIKE US TO DO TODAY? ARE YOU HAPPY WITH THE APPEARANCE OF YOUR TEETH/GUMS/SMILES? Y / N WOULD YOU LIKE TO DISCUSS ENHANCING THE APPEARANCE OF YOUR SMILE? Y / N WOULD YOU LIKE TO DISCUSS HOW TO MAKE YOUR TEETH WHITE? Y / N PLEASE, TELL US ABOUT YOUR HOMECARE: PLEASE, CIRCLE IF YOU HAVE HAD ANY OF THE FOLLOWING: Sensitivity/pain to: sweets biting hot cold Headaches Migraines Clenching Grinding Head/Neck Injuries Clicking/Popping Jaw Sores/growths Bad Breath Bleeding Gums Food Impaction FORMER DENTIST: DATE OF LAST VISIT: DATE OF LAST X-RAYS: IS THERE ANYTHING ELSE YOU THINK WE SHOULD KNOW?
5 NAME OF PERSONAL PHYSICIAN:! Health History DATE OF LAST VISIT: ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN? Y / N If yes, please tell us more about that: HAVE YOU BEEN DIAGNOSED WITH ANY DISEASES OR ILLNESSES? Y / N If yes, please tell us more about that: PLEASE LIST ANY OVER-THE-COUNTER OR PRESCRIPTION MEDICATIONS YOU TAKE: PLEASE LIST ANY ALLERGIES YOU ARE AWARE OF: DO YOU USE TOBACCO? Y / N If yes, please tell us more about that: ARE YOU PREGNANT? Y / N ARE YOU NURSING? Y / N
6 ! Use and Disclosure of Protected Health Information Consent Use of this form is optional and not required under the HIPAA privacy rule. I hereby give my consent for Red Bank Smiles to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Red Bank Smiles describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Red Bank Smiles reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Benjamin Klayman, 180 River Road Red Bank, NJ. With this consent, Red Bank Smiles may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, Red Bank Smiles may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, Red Bank Smiles may to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Red Bank Smiles restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow Red Bank Smiles to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Red Bank Smiles may decline to provide treatment to me.
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Personal Information Last Name First Name Pref. Name MI Mailing Address Apt # City State Zip Home# ( ) Cell# ( ) Sex: M F E-Mail: Confirmation of Apts by Email? Yes No Date of Birth / / SSN#: Marital Status:
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
DENTAL HISTORY. When was your last dental visit? Please describe the main reason for your consultation/new patient appointment:
DENTAL HISTORY When was your last dental visit? Please describe the main reason for your consultation/new patient appointment: DO YOU HAVE ANY OF THE FOLLOWING: Discolored or dark teeth? _ Yes _ No Chipped,
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
WORKERS COMPENSATION - NO FAULT. Patient Name Patient Address. Patient's SS# Date of Birth Attorney Name _ Phone Number WORKERS COMPENSATION
WORKERS COMPENSATION - NO FAULT Patient Name Patient Address Patient's SS# Date of Birth Attorney Name Phone Number -------- WORKERS COMPENSATION Insurance Carrier & Address Insurance Carrier Phone Number
12. Is there anything we can do to enhance your smile and optimize your oral health? Yes No Tell us more:
Smile and Oral Health Evaluation Thank you in advance for taking the time to allow your new dental team the opportunity to get to know you better. Where applicable please rate your responses from 1-10
Patient Information Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
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
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
PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to 949-553-3561, email to Stacie@thephysiofix.com or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient