Talia Pike DMD Patient Information
|
|
|
- Jodie Sparks
- 6 years ago
- Views:
Transcription
1 Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Address Parent Name Birthdate Employer SSN: Work # Cell # Address How did you hear about our office? Is it ok to leave messages regarding confirming appointments, insurance questions, etc? What is the reason for your child s visit today? Dental Insurance Information (please fill out ONLY if insurance card not present) Primary Policy Holder Name Birthdate SSN# Employer s Name & Address Insurance Name & Address ID # Group # I authorize my insurance to pay directly to Dr. Pike if my insurance plan is taken by Dr. Pike. If I am covered by any other plan, I will pay in full when services are rendered. I understand that all insurance policies are different and I am responsible for knowing my plan provisions. I understand I will be responsible for all co-payments, deductibles and any charges that are denied by my insurance plan. Signature of Parent/Guardian: Date: 1
2 Health History yes no Is your child in good health? Child s doctor yes no Has your child ever had a health problem? If yes, please explain_ yes no Are your child s immunizations up to date? yes no Has your child had any operations? If yes, please explain_ yes no Is your child currently taking any medications? If yes, please list yes no Does your child have any known allergies? If yes, please list Please circle if your child has ever been diagnosed with or treated for any of the following: ADD/ADHD Cancer/Tumors Heart Condition/Murmur Psychiatric Care AIDS/HIV Cerebral Palsy Hepatitis Rheumatic Fever Anemia Cleft Lip/Palate Kidney Disease Sinus Problems Asthma Diabetes Liver Disease Social Delays Autism Epilepsy/Seizures/Convulsions Mental Delays Speech/Hearing Problems Birth Defects Excessive Bleeding Measles Stomach/GI Disease Bladder Problems Fainting Mumps Tuberculosis Blood Disorder/Transfusion Frequent Headaches Physical Delays Other Please describe anything circled above Any habits? (finger/thumb sucking, pacifier use, biting nails, etc.) To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform Pike Pediatric Dentistry if my child ever has a change in health. Signature of Parent/Guardian: Date: 2
3 Dental History yes no Has your child ever been to the dentist? Date of last visit Name of previous dentist yes no Has your child ever had dental x-rays? yes no Do you think your child will react well to dental treatment? If not, please explain yes no Does your child use fluoride toothpaste? yes no Do you give your child any fluoride supplements? yes no Have your child s teeth ever been injured? If yes, when? How many times a day are your child s teeth brushed? How many times a week are your child s teeth flossed? Please circle if your child has any of the following: Cavities Gum Infection Sensitive Teeth Braces Discolored Teeth Jaw Sounds Toothache Grinding Loose Teeth To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform Pike Pediatric Dentistry if my child ever has a change in health. Signature of Parent/Guardian: Date: 3
4 Consent for Dental Treatment I request and authorize Dr. Pike and her staff to examine and provide my child with comprehensive dental treatment including, but not limited to cleanings, fillings, crowns, extractions, and nitrous oxide, if required. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Pike to diagnose and/or treat my child s dental condition. I understand that I will be responsible for any charges incurred on this child for dental treatment. I will allow photographs to be taken of my child and/or my child s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Pike will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. Signature of Parent/Guardian: Date: Non-Guardian Consent I give my permission for the following person(s) to accompany my child to his/her dental visits. All person(s) listed below must be over the age of 18. This includes making decisions regarding treatment that may arise during the scheduled appointment. This also gives Dr. Pike and her staff permission to discuss treatment and conditions with the person(s) listed below. I understand that I am responsible for payment at the time of services and should someone accompany my child other than myself, arrangements for payment must be made before the scheduled appointment time. Name Relationship to child 4
5 Financial Policy Please understand that financial arrangements are made directly with you. For your convenience, the following outlines our financial policies: 1. Payment is due in full for each appointment as services are rendered and is to be paid by the person accompanying the child. We accept cash, MasterCard, Visa, Discover and Care Credit. You will be responsible for payment of all costs and fees incurred, including attorney's fees, should collection efforts be made in order to fulfill a debt. 2. Dental Insurance: Please check with our staff to make sure that we accept your child s insurance plan. For all insurances that we do not accept, we will be happy to submit a claim to your insurance electronically, however payment is due in full at time of service. The type of plan chosen by you and/or your employer determines your insurance benefits. As such, we have no control over the terms of your contract, the method of reimbursement or the determination of your insurance benefits. Any reimbursements by your insurance company other than those we directly participate with should be made directly to you according to the terms of your contract with them. 3. Pre-treatment Authorization: Some insurance companies recommend an estimate of the work to be done and the fees to be charged before determining their benefits to you. If so, we will provide you with the pre-treatment fee estimate. In this case, it will be up to you to determine if you wish to proceed with the treatment before the insurance benefit is determined. 4. Fillings: Our dental material of choice is a white (composite resin) filling. Please be aware that your insurance company may not pay for a resin filling at the same level as a silver (amalgam) filling. The co-payment is your responsibility. In some cases, Dr. Pike may recommend placing a silver crown instead of a resin filling. 5. Nitrous Oxide / Analgesia: Our office uses Nitrous Oxide Analgesia (Laughing Gas) for the comfort of our young patients. This fee is not always covered by dental insurance. We thank you for your payment on the date of service. 6. Appliances: The entire cost of the appliance must be paid on the day your child s impressions are taken. This is necessary because our office must pay the laboratory bills when appliances are ordered, not when they are completed. 7. Emergency Treatment: All emergency treatment must be paid in full at the time the service is rendered. Please remember, even if you have insurance coverage, you are responsible for payment of your account. Understand that your insurance coverage is a relationship between you, the insured patient and your insurance company. Your understanding and cooperation with this matter is greatly appreciated. Past due accounts are subject to a monthly service charge and will be turned over for collection by an outside agency.if your account is turned over to a collection agency, all court costs and attorney fees will be applied. I have read and understand my obligation. 5
6 Notice of Privacy Practices-HIPAA I had the opportunity to read over the HIPAA guidelines and ask any questions that I had regarding HIPAA. Signature of Parent/Guardian: Date: Office Policies The office attempts to schedule appointments at your convenience and when time is available. If your child is under the age of 5, we recommend that you schedule a morning appointment for your child. Younger children are more cooperative when they are well rested. Since appointed times are reserved exclusively for each child, we ask that you please notify our office 24 business hours in advance of your scheduled appointment time if you are unable to keep your appointment. We realize that unexpected things can occur, but we ask for your assistance in this regard. If your child misses an appointment without notifying us 24 business hours in advance, a cancellation fee will be applied to your account. This fee will vary depending on the length of time reserved for your child. We try our best to accommodate our patients, so please be courteous and let us know if you cannot make it to your child s scheduled appointment. As a courtesy, our office calls to confirm all scheduled appointments. We kindly ask that only 1 (one) parent &/or guardian accompanies the child in the treatment room for any dental treatment needed (ex. fillings, extractions etc.). Siblings are not permitted to sit on their parent s lap. I have read and understand the Office Policies and agree to abide by its contents: 6
7 Consent for Attempted Treatment To all patients where treatment is attempted, but not completed due to lack of cooperation or other unforeseen circumstances, a fee based upon time and materials used will be charged (ex. chair time, nitrous oxide, local anesthesia). Please understand that time was set aside for your child in order for treatment to be performed. If your child is uncooperative, we reserve the right to charge for our time and materials used/opened. Thank you for understanding! Attempt Treatment (chair time for treatment) (DATTX) $50.00 Nitrous Oxide (D9230) $75.00 Temporary Filling (in case treatment is started, but cannot be completed) (D2940) $85.00 *Please note: if the patient has insurance, the temporary filling (D2940) will be billed out and may be covered. Co-insurance deductible and co-pay will apply. In some instances, nitrous oxide (D9230) may also be covered. IF YOU DECIDE TO CHOOSE IV TREATMENT IN OUR OFFICE, WE WILL PUT THESE CHARGES PAID TOWARD THE IV TREATMENT. Confirmation of Appointments We have an automated system that confirms appointments by and text. If the appointment is not confirmed, the office will also attempt to call you to confirm the appointment. TEXT Best number to text: PHONE CALL Best number to call: Updated address (if moved): 7
Talia Pike DMD Patient Information
Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Email Address Parent Name
PATIENT INFORMATION. Parent/Legal Guardian #1: Name: Date of Birth: / / Occupation/Employer: SS#: Work phone: Mobile: Home: address:
! PATIENT INFORMATION Your Child s Name: Nickname: Date of Birth: / / Age: Identifies Male: Female: School: Grade: Child s primary address: City: Zip: Telephone: Parent/Legal Guardian #1: Name: Date of
*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*
DR. MILES MAZZAWI DR. ANTHEA DREW MAZZAWI DR. NIRALI PROCTER 205 Waleska Rd. Suite 2-B Canton, GA 30114 (770) 479-1717 Today s Date: / / We are so pleased to welcome you and your child to our practice!
Little Peaches Pediatric Dentistry
Little Peaches Pediatric Dentistry Patient Information Date: Child s name: Nick Name: Date of Birth: Grade: Sex(circle): Male / Female School: Home Address: Street City, State Zip Code Dental Insurance:
Pediatric Dentistry Health History
Pediatric Dentistry Health History Child s Full Name: Nickname: Sex: M F Date of Birth: / / Age: SSN # Best Phone # ( ) Grade: School: Name(s) and ages of other children in family: Name(s) of your other
INSURANCE INFORMATION
To provide the safest and most comprehensive dental care for your child, we ask for your cooperation in completing our detailed questionnaire. Date: Child s name: Nickname: Birthdate: Gender: M F Home
CHILD S INFORMATION PARENTS INFORMATION
104 E. Olive Ave., Suite 200 Redlands, CA 92373 Phone (909) 798-0604 Fax (909) 798-9765 www.just4kidsdentistry.com WELCOME NEW PATIENT MEDICAL AND DENTAL HISTORY CHILD S INFORMATION Child s Name: Nickname:
Child s Name: Last First Middle Preferred Name. Address: Street Apt.# City State Zip. Mother Stepmother Guardian. Name: Employer: Social Security #:
Today s Date We are so pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we ll be glad to help
Worcester Kids Dentist 41 Lancaster Street, Worcester, MA Child Health History. Name of Child
, Child Health History Name of Child DOB 1) Were there any difficulties during the pregnancy, delivery or first year of life? Yes No 2) Is a physician treating your child now for a specific illness? Yes
NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK
PATIENT INFORMATION NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - ADDRESS CITY STATE ZIP HOME PHONE CELL OTHER EMAIL How did you hear about our office? HEAD OF HOUSEHOLD NAME: LAST FIRST MI
CHILD S REGISTRATION & HISTORY
SIMON P. MORRIS, D.D.S. MAI DINH D.D.S., M.S. CHILD S REGISTRATION & HISTORY Child s name FIRST MIDDLE LAST Nickname Date of birth Age Male Female Child s interests Pets Other children in family who are
Patient Information. Responsible Party. Notify in case of emergency?
We are pleased to welcome you and your child 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
PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
New Patient Packet. Patient Name: Today s Date: Last First MI. Preferred Name: Gender: Birth Date: Apartment Number
Patient Information New Patient Packet Patient Name: Today s Date: Last First MI Preferred Name: Gender: Primary Number: (C/W/H) Secondary Number: (C/W/H) Address: Best Email Address to Confirm Appointments:
HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance
HEALTH HISTORY FORM 4 How Did You Hear About Us? 5 Who is Accompanying the Child Today? Name Today s 1 2 3 Tell Us About Your Child Patient s Full Name Preferred Name Male Female Siblings We Treat Patient
Child s Name: (First) (Middle) (Last)
Child s Name: (First) (Middle) (Last) Sex: M F Age: Birth date: / / Place of Birth: School: City: Pediatrician Name: Whom may we thank for referring you to our office? Name(s) of Sibling(s): WHAT IS YOUR
David L. Rothman, dds Pediatric Dentistry
Complete forms, print out and sign. Bring completed forms to your office visit. 1/7 pages Name: nickname: Sex: Male Female Birthdate: age: School: Is this your child s first dental visit? Yes No Is this
NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. Insurance Co. Name Name
Health History Form Dr. Lisa LaPresti Today s Date: NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. 1. Tell Us About Your Child 5. Child s Name
All About Kids Pediatric Dentistry
Dr. Courtney Wilson & Dr. Melanie Nesbitt Patient Registration Date: Patient s Name Nickname Birth date Age Sex Patient s Address Contact Phone # street city state zip Father s Name DOB Mother s Name DOB
Mother s Name: Birth date: SSN: Home Address: City State Zip Home Phone# Work # Cell # Address Employer
Kid City Smiles Mary Beth Tabor, DDS 107 Maple Row Blvd Hendersonville, TN 37075 615.822.5588 615.822.3206fax Child s Name Today s Date Home Address City_State Zip Home Phone# Work # Cell # Date of Birth
2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)
2460 India Hook Road, Suite 106 Rock Hill, SC 29732 E-mail: drj@rockhillkids.com Tel: (803) 327-3327 Fax: (803) 334-3474 Welcome to our practice! Please carefully complete this form so that we may better
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
Just for Kids Pediatric Dentistry, Ltd. Patient Information
Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:
Dental Insurance Information
Dr. Talib Ali DMD Dr. Ali Mualla DDS Patient s Name Social Security # Gender Birthdate Email Address Home Address City State Zip Home Phone Cell Phone Most Recent Dental Visit Who may we thank for your
Child Health and Dental History Form
Child Health and Dental History Form Child's Name Last First Middle Nickname/Preferred Name Birthday / / Address: Street City State Zip Gender: Male Female Parent Info (please circle): Mother Father Guardian
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,
Doc Bresler s Cavity Busters - New Patient History Form
Doc Bresler s Cavity Busters - New Patient History Form Patient s Name Nickname Date of Birth Age Female Male Address City,State,Zip Code Home Phone Mother s Name Occupation Email Address Cell Phone Father
PATIENT REGISTRATION & HISTORY
PATIENT INFORMATION Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT,
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
1. Tell Us About the Patient. 2. Legal Guardian #1 Information. Child s Name Last. Preferred name. Grade. Patient s Age. School. Patient s Birth Date
1. Tell Us About the Patient Child s Name Preferred name Male Grade School Patient s Birth Date Patient s Age Patient s Home Address City State Patient s Home ( Zip Siblings that we treat? 2. Legal Guardian
Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
Welcome! $pectali:zlftg in de~ftlv all c/n'td/u3ft
Welcome! It is with great pleasure that we welcome you to our office. We would like to thank you for selecting Kids First Pediatric Dentistry for your child(ren)'s oral health needs. Be assured that this
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
Part Four: Who is Accompanying the Child Today? Part One: Tell Us About Your Child. Part Five: Referral. Part Six: Person Responsible for Account
Kee Kwak, DDS 2426 Beltline Road Garland, TX 75044 New Patient Health History Form Print this form, complete all information, and bring it with you on your first visit to our office. The parent or Guardian
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 {
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Date / / Welcome Patient s Name Last First M.I. Address City State Zip Code Home Phone
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
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
Pediatric Dental Safari
Pediatric Dental Safari Amita Damani DDS, PA New Patient Form Child s Name: Nickname: Sex (M) (F) Purpose of Visit: Concerns: Birthdate: Child s Interests: Name of Pet(s) Does your child have any special
Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment
PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our
Personal Information. Date of Birth: / / SSN: - - Single Married Child Other. Home Address: Street City State Zip
Dr. Harvey Levy & Associates, P.C. 198 Thomas Johnson Drive, Suite 108, Frederick, MD 21702 Office: (301) 663-8300 Fax: (301) 682-3993 E-mail: appointments@drhlevyassoc.com Personal Information Patient
Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
![Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell](/thumbs/95/122853379.jpg "Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell")
Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred
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
Patient Health History
Dentistry for Infants, Children, Young Adults & Patients with Special Needs Patient Health History Please complete the following health history for your child. This information is essential in making a
Today s Date / / Male Female. Child s Name Preferred Name. Child s Address City Zip. How were you referred to our office?
Today s Date / / Male Female Child s Name Preferred Name Child s Birthday / / Cell # ( ) - Home # ( ) - Child s Address City Zip How were you referred to our office? Who is accompanying this child today?
Patient Information Patient Name:, Patient Last Name Patient First Name MI Preferred Male Female Family Status: Married Single Child
Patient Information Patient Name:, Patient Last Name Patient First Name MI Preferred Male Female Family Status: Married Single Child Birthdate Social Security Number e-mail address Home address City State
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Dental Smiles for Kids
Dental Smiles for Kids Ronkonkoma Office Phone: 631-451-7700 Astoria Office Phone: 718-278-1700 Whitestone Office Phone: 718-746-1230 Centereach Office Phone: 631-585-6600 Health History Form Today s Date:
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
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
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
X X Capistrano Children s Dentistry Child Patient Information
X X Capistrano Children s Dentistry Child Patient Information Your Child Name: Nickname: Home Address: Birthdate: Age: Sex: Home Phone: School: Pediatrician: Please list names of other siblings previously
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
Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information
Welcome To Concord Pediatric Dentistry Patient Information Patient s Name: First Middle Last Name child goes by: Sex: Mailing Address Street City State Zip Date of Birth: Age: Weight: Child Lives with:
SPOKANE PEDIATRIC DENTISTRY PATIENT REGISTRATION
SPOKANE PEDIATRIC DENTISTRY PATIENT REGISTRATION Spokane Pediatric Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,
Conte See Oue Exei^ing
CoDcorcf %di^tvic D Dtisti?y 16 foundry Itreet, Co^corcf Conte See Oue Exei^ing nolttel Immediately off 1-93 at Exit 16 (see directions below) Please call our office for details. Direct Jons From North:
Previous Dentist: Date of Last visit: Date of Last X ray:
Marilou Navarro DDS & Associates Tell Us About Your Child Today s Date: Child s Home Phone#:( ) Social Security # Child s Name: Child s Birthdate: / / Child s Age: School: Grade: Male Female Who may we
Name. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address
405 S. Granite Ave. PO Box 959 Granite Falls, WA 98252 tel (360) 691-7793 fax (360) 691-5577 www.cervendentistry.com To help us better serve the needs of your child and meet his/her dental healthcare needs,
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Date / / Welcome Patient s Name Last First M.I. Address City State Zip Code Home Phone
Welcome to Pediatric Dentistry of Greenville!
Welcome to Pediatric Dentistry of Greenville! Child's Information Child's Name(Last, First, Middle Initial) Child's DOB: / / Child's Age Nickname: ( ) Male ( ) Female School : Grade: Child's Home Phone
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 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
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.
Sincerely, Dr. Mischelle and Staff
Welcome to the office of Dr. Mischelle Doll, Specialist in Pediatric Dentistry. We welcome you and your children to our family. We are glad you chose our practice for your children s dental care. Our immediate
Patient Name Preferred Name Social Security. Address City, State, Zip. Home Phone Work Phone Cell Phone. Birth Date Age Driver s License #
Welcome To Our Office! Thank you for choosing us as your dental care provider. We are dedicated to providing you the best dental care. If you have any questions while completing the form, we will be happy
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
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
MEDICAL HISTORY ABOUT YOUR CHILD DENTAL HISTORY M / F
1819 61ST Avenue, Suite 101 Greeley, CO 80634 970-506-1339 Fax 970-339-8500 www.wildforasmile.com ABOUT YOUR CHILD MEDICAL HISTORY Child s Name (First) (MI) (Last) Name child prefers to be called M / F
Patient Safety and Privacy. Appointment Policy
Patient Safety and Privacy For your comfort one adult is welcome, but not required to accompany your child to the treatment areas. We do encourage self independence to help promote the growth and development
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:
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 Registration
Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number:
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
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
Patient Information. Male Female Married Single Child Other. Health Information
Patient Name Patient Information Last, First MI (Preferred Name) D ate: Social Security #: Birth Date: Driver s Lic #: Cell phone Phone (Home): (Work): Ext: Address: Street Apartment # City State Zip Code
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
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: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY:
(PLEASE PRINT CLEARLY) Date: PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY: HOME PHONE: CELL PHONE: WORK PHONE: WHAT PHONE NUMBER IS BEST TO GET A HOLD
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
Dr. Paul Jang Dentistry Health Questionnaire
Dr. Paul Jang Dentistry Health Questionnaire General Information How did you hear about us? Mailer Yelp Referral: Other: Primary purpose of visit: Changing Dentists Cleaning Long overdue for dental visit
4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone
Dr. Jeffrey D. Singer Specialty Permit # 5722 1001 Laurel Oak Road Suite C-2 Voorhees, NJ 08043 Phone: (856) 783 3515 Fax: (856) 783 3517 www.abcchildrensdentist.com PATIENT REGISTRATION 1. Tell Us About
Prefix: First Name: Middle Name: Last Name: Suffix: Name you preferred to be called: Street: ZIP: City: State: Country:
Patient Information Date: Patient Prefix: First Name: Middle Name: Last Name: Suffix: Name you preferred to be called: Street: ZIP: City: State: Country: Date of Birth: Sex: Male Female Unspecified Emergency
PATIENT INFORMATION PARENT / GUARDIAN INFORMATION
PATIENT INFORMATION Child s name: Nickname: Age: Birth date: Male/ Female Names and ages of siblings: Home address: City/State/Zip: Telephone: Child s School: Child s Physician: Address & Phone Number:
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 REGISTRATION
Dr. Jaish J. Markos State License #053850 50 Dayton Lane Ste #103 Peekskill, NY 10566 Phone: (914) 402 6980 www.gckidsdmd.com PATIENT REGISTRATION Date 1. Tell Us About Your Child Child s First 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
Welcome to Tyler L. Smith Family Dentistry
Today s : Patient Information Welcome to Tyler L. Smith Family Dentistry Last: First: Middle Initial: _ Preferred: Address: City: State: Zip: Home #: Email: Cell #: Work #: Sex: Birth : Social Security
Patient Registration PATIENTS WITH DENTAL INSURANCE ALL THIS INFORMATION IS NECESSARY TO VERIFY YOUR DENTAL COVERAGE!!
Patient Registration Patient Name Date of Birth Age If child, Parent's name: Mr. Mrs. Ms. Dr. I prefer to be called Single Married Divorced Widowed M F Address City St Zip. Home Phone( ) Cell Phone( )
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.
NEW PATIENT REGISTRATION FORM (PLEASE PRINT)
NEW PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT INFORMATION Full Legal Name (First) (Middle) (Last) Preferred Name (Nickname) Address Apt. No. City State Zip E-mail Home Phone: Work Phone Cell Phone:
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:
Driver s License # Cell Phone Gender Male Female. Single Married Divorced Other. Driver s License # Cell Phone Gender Male Female
Patient Information: Patient Name Home Address City, State, Zip Home Phone Social Security # Birthdate Driver s License # Cell Phone Email Gender Male Female Work Phone Insurance Information: Marital Status
Patient Information. Patient s Name: Preferred Name: Date of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status:
Patient Information Today s Patient s Name: Preferred Name: of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status: Employer: Occupation: Spouse s Name: Spouse Employed by: Business Phone:
Healthy Smiles Start Here!
Patient s Information Last Name: First: Middle: Preferred Name: Gender: M or F Date of Birth: Age: SSN: Does the patient attend school: Yes or No. If yes, where? Child s physician: Phone #: Address of
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
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 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
Emergency Contact: Name: Phone: ( ) Dental Insurance: YES NO MEDICAID: Certificate # PRIMARY Subscriber name: Subscriber D.O.B.
HENDRICKS PEDIATRIC DENTISTRY 1411 S. GREEN STREET, #200 BROWNSBURG, IN 46112 Ph: (317) 852-8113 Fax: (317) 852-8115 PATIENT REGISTRATION Patient Name Birth date / / (First) (Middle) (Last) (Month/Day/Year)