Jeremy C. Kiersz, DDS Rolla Family Dentistry 1701 E. 10 th Street Rolla, MO (573) Name. First MI Last Preferred Name
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- Easter Washington
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1 Patient Information Jeremy C. Kiersz, DDS Rolla Family Dentistry 1701 E. 10 th Street Rolla, MO (573) Today s Date (Please Print) Name First MI Last Preferred Name Birthdate Male Female Social Security # Marital Status: M / D/ S/ Sep/Widow Address City State Zip Telephone: Home Work Cell Medical History Reason for today s visit Date of last dental exam History of Periodontal Treatment? (Any gum treatment or surgeries) No Yes Tobacco Use? No Yes Primary Care Physician s Name Phone # (Women) Are you pregnant? No Yes If yes, Due date Are you nursing? No Yes taking birth control pills No Yes Are you allergic to any of the following? Amoxicillin Allergy Codeine Allergy Dye Allergy Erythromycin Allergy Latex Allergy Local Anesthetics Metal Penicillin Allergy Septra Allergy Sulfa Allergy Vicodin Allergy Other Do you have a history of the following? Please check each box. Aids Circulatory Problems Hemophilia Respiratory Disease Arthritis Cortisone Treatment Hepatitis Rheumatic Fever Art. Heart Valves Cough Up Blood High Blood Pressure Rheumatism Artificial Joints Diabetes HIV Positive Shortness of Breath Asthma Epilepsy Kidney Disease Stroke Autism Glaucoma Liver Disease Thyroid Blood Disease Headaches Mitral Valve Prolapse Tuberculosis Cancer Heart Murmur Pacemaker Ulcers Chemotherapy Heart Problems Radiation Treatment Venereal Disease Please list all medications you are currently taking: List any surgeries you have had in the past 2 years: 1
2 How did you hear about us? Responsible Party (If minor) Name of parent/guardian accompanying patient today Relationship to patient Social Security # Birthdate Address City State Zip Home Phone # Name of employer Work Phone# Insurance Information Name of policyholder Relationship to patient Birthdate Social Security # Policy ID # Address City State Zip Name of Employer Phone Work Name of Insurance Co. Insurance Phone Insurance address City State Zip Do you have additional insurance? No Yes If yes, please complete the following: Name of policyholder Relationship to patient Birthdate Social Security # Policy ID # Address City State Zip Name of Employer Phone Work Name of Insurance Co. Insurance Phone Insurance address City State Zip I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Signature of Patient/Parent/Guardian 2
3 Rolla Family Dentistry 1701 E. 10 th Street, Rolla, MO (573) Thank you for choosing Rolla Family Dentistry. Our mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options: You can choose from: Cash, Check, Debit Card, Visa, MasterCard, American Express or Discover Card NO INTEREST Payment Plans from Care Credit Allow you to pay over time with NO INTEREST Convenient, low monthly payment plans also available No annual fee or prepayment As a courtesy, we will gladly file your insurance with your insurance company. However, all charges are the responsibility of the patient or guardian. If we have not received payment from your insurance company within 60 days of filing, you will be sent a statement to pay the balance. When the balance is zero, we will send you a completed claim form to file to your insurance company. If we are unable to verify your insurance coverage while you are in the office, you are required to pay the entire amount and we will give you a claim form to file to your insurance company. No one likes surprises at the end of a dental appointment. If you have any questions regarding your treatment or payment obligations, please ask to speak to the doctor or to a front desk person. I do not have dental insurance and I agree to pay for any and all treatment IN FULL on the day of service. I have dental insurance and am responsible for paying my estimated portion on the day services are rendered. I have read the above and understand the contents Patient, Parent or Guardian Signature Date 3
4 HIPAA I authorize release of my Protected Health information for discussion of my care and treatment or payment to the person(s) listed below. Please list any friends/family we can discuss treatment, appointments or financial information with in the box below. Signature Date Consent for Communications Name First MI Last I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured website for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me, and that the dental practice is not liable for any changes, damages, or losses that may be incurred of suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of the Agreement and thereafter, comply with all laws directly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all person or entities under the direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THIS SITE OR THE SERVICES. I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the website. Signature of patient, parent, or guardian: Signature Date 4
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PATIENT REGISTRATION
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PATIENT REGISTRATION
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12. Is there anything we can do to enhance your smile and optimize your oral health? Yes No Tell us more:
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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 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
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:
Anthem Hills Dental PATIENT INFORMATION
PATIENT INFORMATION Patient Name DOB Date Address City ST Zip Preferred Contact # Home # Cell # E-mail _ SSN Marital Status: S M Other Employer Type of Work Work # Business Address_ City ST Zip Emergency
Dental/Medical History Form
Dental/Medical History Form Name Social Security # / / FIRST MIDDLE LAST Date of birth / / Age Male/ Female Status: Married /Single /Divorced / Widowed / Separated Address City State Zip Home Phone ( )
117 FLORAL VALE BLVD, YARDLEY, PA PHONE: FAX: PATIENT INFORMATION
117 FLORAL VALE BLVD, YARDLEY, PA -19067 EMAIL: radiantsmiles2009@yahoo.com PHONE: 215-860-4600 FAX:215-860-1455 PATIENT INFORMATION Patient s Name: (Last) (First) (MI) Address: (Street/Apt.) (City) (St)
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)
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.
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:
Patient Information. City State Zip Code. Date of Last Dental Visit: Reason for this visit: Health Information
Chart #: Patient Information Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Birth Date: Family Status: Date: Phone (Home): (Work): Ext: (Cell) Email: Street Apartment # City State
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: