Welcome to CitiDental
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- Barbara Wright
- 6 years ago
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Transcription
1 Date: Welcome to CitiDental Patient Information: Name D.O.B. SS# Address Apt Town State Zip Marital Status Home Phone Cell# Other Employer Work Phone EMERGENCY CONTACT: Name Phone Responsible Party: (if different from above) Name Address SS# Birth date Whom May we thank for this referral? (current patient, Yellow Pages, website, etc) Dental Insurance Information: check if does not apply Name of person carrying insurance Insurance Company Name Insurance ID # or social security # Insured s D.O.B Group Number Insured employer name Do you have another dental insurance? Dental History: How can we help you today? Former Dentist s Name: Date of last dental visit? How often do you brush? How often do you floss? PLEASE CHECK ALL THAT APPLY: Y or N Bad Breath Y or N Food Collects between teeth Y or N Pain around ear Y or N Bleeding Gums Y or N Foreign Objects Y or N Periodontal Treatment Y or N Blisters on lips/mouth Y or N Grinding teeth Y or N Sensitivity to cold Y or N Burning on Tongue Y or N Gums swollen or tender Y or N Sensitivity to hot Y or N Chew on one side of mouth Y or N Jaw pain or tiredness Y or N Sensitivity to sweets Y or N Cigarette or cigar smoking Y or N Lip or cheek biting Y or N Sensitivity when biting Y or N Clicking or popping jaw Y or N Loose teeth/broken fillings Y or N Sores in mouth Y or N Dry mouth Y or N Mouth breathing Y or N Orthodontic Treatment Y or N Fingernail biting Y or N Mouth pain Patient Name Date
2 Please answer the following questions: 1. Have you ever taken pre-medication (antibiotics) before dental visits? Y or N 2. Have you had any periodontal treatment (gum treatment) in the past? Y or N 3. Do you have sensitivity to hot, cold, sweets or when chewing? Y or N 4. Do you take Aspirin (Bayer, Bufferin) on a regular basis? Y or N 5. Have you ever taken Bisphosphonates (Fosamax, Boniva, Actonel)? Y or N 6. Have you ever been diagnosed with a problem with either jaw joint? Y or N 7. Does your jaw click, pop, or make noise when you open and close? Y or N 8. Is there pain or tenderness in your jaw joint when you open, close or chew? Y or N 9. Has your jaw ever locked open or closed? Y or N 10. Do you have frequent headaches? If so how often? Y or N 11. Do you clench or grind your teeth, or ever been told you do? Y or N 12. Have you ever had trauma to your chin or jaw? Y or N Medical History: Physician s Name Date last visit? (approx) Additional Specialist doctors: Date of last visit? Please circle Y (yes) or N (no) for ALL medical conditions listed below: Y or N Aids/HIV Y or N Jaundice Y or N Blood Disease Y or N Cortisone Treatments Y or N Sinus Trouble Y or N Glaucoma Y or N Heart Problems Y or N Artificial pins, joints Y or N Mitral Valve Prolapse Y or N Respiratory Disease Y or N Diabetes Y or N Thyroid Problems Y or N Anemia Y or N Kidney Disease Y or N Cancer Y or N Circulatory Problems Y or N Stroke Y or N Headaches Y or N Hepatitis (type ) Y or N Asthma Y or N Pacemaker Y or N Rheumatic Fever Y or N Epilepsy Y or N Tumors or growths Y or N Arthritis Y or N Liver Disease Y or N Chemical Dependency Y or N Congenital Heart Lesions Y or N Skin Rash Y or N Heart Murmur Y or N High Blood Pressure Y or N Abnormal Bleeding Y or N Radiation treatment Y or N Scarlet Fever Y or N Fainting/dizziness Y or N Ulcers Y or N Artificial Heart Valves Y or N Low Blood Pressure Y or N Venereal Disease Y or N Persistent cough Y or N Swollen neck glands Y or N Weight Loss, unexplained Y or N Psychiatric disorders Y or N Depression Y or N Herpes Women: Are you Pregnant Nursing Taking Birth Control Pills? Have you ever taken any group of drugs that are affiliated with Fen-phen? Yes or No Please List ALL medications you are taking, the amount and frequency for each: Allergies: Do you have any allergy to any of the following OR medication? Please circle any that apply Latex Aspirin Barbituates (sleeping pills) Penicillin Codeine Iodine Sulfa Local Anesthetic Other SIGNATURES: Please sign below: PATIENT or guardian / / DOCTOR/R.D.H / /
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5 CitiDental ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this Acknowledgement** I, have received a copy of this office s Notice of Privacy Practices. Please print Name Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices. Acknowledgement could not be obtained because: o Individual refused to sign o Communication barriers prohibited obtaining the acknowledgement o An emergency situation prevented us from obtaining acknowledgement o Other (please specifiy)
6 Attention Insured Patient, In order to submit claims accurately, the following are needed: 1. We need all necessary information on the policy holder. 2. Information does need to be verified by the insurance company. Note: Information provided by the insurance company IS NOT A GUARANTEE OF BENEFITS, only an estimation. Please review your policy book so there are no misunderstandings. If you do not have a policy book, contact your human resource office. You, the patient, are responsible for your own policy, we are third party billing only, and given minimal information by your insurance company. You are responsible for all co-pays at time of service, and any balance that may occur after the insurance has paid. We do send dental pretreatment estimates to your insurance if treatment is diagnosed and discussed. This is done to have approval on file if treatment is rendered. It is NOT submitted for reimbursement until actual services are performed. OUR GOAL: To give you the best estimate possible with the information given to us by your insurance company. Until the insurance company receives the actual CLAIM, it remains an ESTIMATE and not a GUARANTEE. TREATMENT PLANS AVAILABLE. By signing below, I authorize direct payment of the insurance benefits to CitiDental and its associate doctors, for treatment rendered to me and/or my child/children. I have read and understand the above policies. Patient/parent/guardian Date
7 Office Policies Of CitiDental FINANCIAL AGREEMENT: Payment is due at time of service Financial assistance is available, upon credit approval. As a courtesy to you, we will submit all charges to the insurance company. Insurance is designated to cover a portion of the customary fee. Co-payments are collected at time of visit. (Please see our insurance policies.) BALANCES LEFT ON ACCOUNT FOR OVER 60 DAYS: All parties will be responsible for the cost of collection, which may include but is not limited to any and all collection and legal fees. Returned checks: There will be a $25.00 fee. Initial CANCELLATION AND FAILURE TO ARRIVE: We understand that circumstances do arise that can keep you from a dental appointment. Please, have the courtesy to give the office 72 hours notice. Please understand that we have reserved the doctors time for you and we will try to contact you at all phone numbers listed to confirm your appointment. There will be a $75.00 charge for all appointments missed or cancelled without 72 hours notice. Initial To reserve a treatment appointment with one of our Specialists on Staff (perio or endo), there will be a deposit of $ required at time of scheduling which is applied towards any dental co-payment. 72 hours notice needed for cancellation. There will be a $ charge for all specialist appointments missed or cancelled without 72 hours notice. Initial X-RAYS: Digital x-rays are the property of CitiDental. If you wish to have your x-rays ed, a notice of 24 hours is necessary. PRIVACY NOTICE: Privacy Act: I give CitiDental permission to send reminder postcards to me through U.S. Postal Service, and to leave messages via answering machine, voic , , cell phone, or other family members. By signing below, I understand the above listed policies, and assume responsibility for all services rendered. Patient/Parent/Guardian Date
Dental Registration and History
~) Patient Information (PLEASE PRINT) ftj. Dental Insurance Date Who is responsible for this account? SS/HIC/Patient ID # Relationship to Patient. Patient Name----,------,--,-, Last Name Insurance Co.
DENTAL REGISTRATION AND HISTORY
DENTAL REGISTRATION AND HISTORY 1. PATIENT INFORMATION Date Patient Name Last Name First Name Middle Initial Address E-mail City State Zip Sex M F Age Birth date Married Widowed Single Minor Separated
Consent for Treatment
Consent for Treatment 1. I hereby authorize doctor or designated staff to take radiographs, study models, photographs, and other diagnostic aids appropriate by doctor to make a thorough diagnosis of dental
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
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
HEALTH HISTORY. Physician s Name Phone# Date of Last Visit
HEALTH HISTORY Physician s Name Phone# Date of Last Visit Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combination of Ionamin, Adipex, Fastin (brand
WELCOME TO THE PROVINCES DENTAL CARE
WELCOME TO THE PROVINCES DENTAL CARE Name Nickname Address Unit# Birth Date Age Sex City State Zip Single Married Widowed Other Home Phone Social Security # Work Phone Employer Cell Phone Occupation E-Mail
Patient Information. Dental Insurance. Emergency Contact
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. Patient Information Date Patient
DENTAL REGISTRATION AND HEALTH HISTORY
DENTAL REGISTRATION AND HEALTH HISTORY PATIENT INFORMATION Soc. Security #/Patient ID #: Patient Name: Gender: Date of Birth: Age: E-mail: Phone (Home): (Work): Ext: (Cell): Address: City: State: Zip:
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
PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address:
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
Michael Mabry, DDS, MAGD
PATIENT INFORMATION Date: / / PATIENT NAME: Last First Middle Initial Male Female Date of Birth: Married Widowed Single Minor Separated Divorced Partnered ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK PHONE:
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
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
Subscriber's Name. Date of Birth. Secondary Insurance Group # ID # DENTAL HISTORY. Yes Yes Yes Yes Yes Yes Yes Yes Yes
PATIENT INFORMATION Last Name First Name Middle Sex: Marital Status: of Birth SSN Address City State Zip Code E-mail Phone # Cell # Contact preference: Employer/School Occupation Employer/School Address
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
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
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
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: 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
Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:
Dental History Medical History Reason for today s visit: _ Former Dentist:_ Date of last dental visit_ Date of last dental x-rays_ Mark Yes or No to indicate if you presently have or previously had any
Prince Family Dentistry
Prince Family Dentistry 702-240-0202 830 S. Durango Dr., Ste. 104 Las Vegas, NV 89145 PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married {
Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
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)
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
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 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
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
Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n
Shore Smiles Family & Cosmetic Dentistry 654 Newman Springs Road, Lincroft, New Jersey 07738 Phone: 732-747-4444 Fax: 732-747-4003 Welcome Take a few minutes to answer the following questions so we can
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 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
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:
WELCOME TO OUR PRACTICE
WELCOME TO OUR PRACTICE We will like to know your dental concerns and expectations so we can provide you with the best dental care. What are your dental concerns? What would you like to improve, if anything,
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
Primary Insurance Information
Durell Family Den-stry 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.
Please print name and Relationship to patient Dental/Medical History Are you having pain or discomfort at this time? Y N Do you feel very nervous abou
Personal Information Patient Registration Form Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Email Address Birthday Sex: M F Marital Status: S M W Sep D Social Security
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:
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Welcome Date / / Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Patient s Name Last First M.I. Address City State Zip Code Home Phone
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
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 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 Information & Demographics
ARTISTRY INTEGRITY PASSION 101 NORTH MARY STREET HEDGESVILLE, WV. 25427 NEW UPDATE Patient Information & Demographics Appointment : Appointment Time: am pm Name: Nickname: Address: of birth: SS# Marital
PATIENT INFORMATION BILLING & INSURANCE INFORMATION DENTAL HISTORY
PATIENT INFORMATION Patient name Date of birth Sex Age SSN# Home address City State Zip Home Phone Cell Email Emergency contact Emergency phone I would prefer appointment reminders by: text email both
Candace L. Peterson, DMD
Candace L. Peterson, DMD PATIENT REGISTRATION Date A. Responsible Party SS # - - Last First Middle Home Address Birthdate E-mail City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Employer
Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:
David B. Epstein DDS 1 0 0 1 M E D I C A L P L A Z A D R # 3 0 0, T H E W O O D L A N D S, T X 7 7 3 8 0 281-367- 3 0 8 5 d r e p s t e i n @ t h e w o o d l a n d s d e n t a l. c o m Patient Information
Patient Information. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
P A T I E N T R E G I S T R A T I O N
900 MAIN STREET, SUITE 104 RICHARD H. CHANIN, D.D.S GREG B. CINSKI, D.M.D. COSMETIC & FAMILY DENTISTRY www.holbrooksmiles.com P A T I E N T R E G I S T R A T I O N Today s Date Name Preferred Address Telephone:
Responsible Party Information
3521 COMMERCE CT APPLETON, WI 54911 (920)-734-7730 WELCOME TO OUR PRACTICE Patient Name Preferred Name (Last Name) (First Name) (MI) Gender: Male / Female Family Status: Minor / Single / Married / Other
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
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:
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 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
Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
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,
3 Home Work Cell Best time to reach you (Specify someone who does not live in your household.) Name Relationship Home Phone Work/Cell Phone
1 2 Date Patient Address City State Zip Sex: M F Age Birthdate Single Married Widowed Separated Divorced Patient SS# Occupation Employer Employer Address Employer Phone Spouse s Name Birthdate SS# Occupation
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
All Dental 76 Otis Street Westborough, MA 01581
All Dental 76 Otis Street Westborough, MA 01581 Date: SSN: Primary Care Physician: Physician Phone: Patient Information Patient Name: Last First Address: City: State: Zip: Birthday: / / Employer: Occupation:
Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone
Patient Information NameSoc. Sec. # Last Name First Name Middle Initial Address City State _ Zip _ Home Phone _ Cell Phone _ Sex M F Birthdate _ Single Married Widowed Separated Divorced Patient Employed
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
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
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:
GRAND STRAND DENTISTRY B Hwy 544. Conway, SC 29526
GRAND STRAND DENTISTRY 1867 B Hwy 544 Conway, SC 29526 I,, hereby authorize Grand Strand Dentistry to give the following people information concerning my health, treatment, billing and/or insurance information:
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
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 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 & HEALTH HISTORY FORM
PATIENT REGISTRATION & HEALTH HISTORY FORM 133 E Main Street, Carlton, OR 97111 Phone: (503) 852-7147 Date: PATIENT INFORMATION First Name: M: Is the patient a student? Full Time Part Time Last Name: Employer:
Jane Otto Family Dentistry Gravois Road St. Louis, MO (314)
Jane Otto Family Dentistry 11521 Gravois Road St. Louis, MO 63126 (314) 842-2442 PATIENT INFORMATION Patient Name: Last First MI Male Female Married Single Child Other: Social Security #: Date of Birth:
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
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
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:
Address Who referred you to our practice? relationship
Health History Form Date Name Home Phone ( ) Cell ( ) Work ( ) Address City State Zip Code Occupation Height Weight Date of Birth Sex M F SS# Emergency Contact Relationship Phone ( ) E-mail Address Who
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?
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:
1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information
Patient Information Patient s Last Name First Name Middle Initial Preferred Name Responsible Party s Name (if not patient) Relationship to the patient Today s Date Family Status: Single Married Divorced
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
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
Philip N. Hodge, DDS, PS
19221 108 th Avenue SE, Ste. 4 Renton, WA 98055 (253) 852-4746 tel (253) 852-4754 fax Welcome to our office. We appreciate the confidence you place with us to provide dental service. To assist us in serving
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,
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 INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed E-mail address:
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
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
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:
Brighter Smiles Family Dentistry
Brighter Smiles Family Dentistry Welcome To Our Office! Our team believes that our patients are the most important people in the world. We appreciate that you have chosen our team as your dental family.
538 SAVANNAH HIGHWAY CHARLESTON, SC (843)
DENTAL HISTORY Name: Reason for today s visit: Previous dentist: Previous dentist s phone number: Date of last dental care: Last dental x-rays: Please indicate any of the following issues that apply with
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred Birth date: S.S.N.# ID/DL#: Month /Day /Year Address: Street Apt. # City State Zip Telephone: Home # Work#
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
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.
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:
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
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.
DENTISTRY RALEIGH PATIENT INFORMATION INSURANCE INFORMATION IMPLANT & FAMILY. Primary Insurance: (PLEASE PRESENT INSURANCE CARD TO RECEPTIONIST)
, RTH CAROLINA 27609 WWW.IMPLANTANDFAMILY.COM PATIENT INFORMATION Preferred Date of Birth: Male Female Married Single Address: Street Phone: Home: City Work: Zip Code Cell: SPOUSE INFORMATION Place of
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
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 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:
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
LONDON BRIDGE SMILES Patient Information (please print) Name Social Sec. # Date of Birth Male/Female First MI Last Address City State Zip Home Phone Cell Phone E-mail Employer Occupation Work Phone Business
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
Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc. Birth Date: Social Security # Previous Visit Date
Welcome to Dr. Peer s Office New Patient Registration Form Patient Name: Last First MI Preferred Name Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc Birth Date: Social
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