Please review the enclosed information. Should any questions arise before your appointment, please contact our office for assistance at
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- Brianna Cook
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1 Welcome to Pacific Northwest Periodontics and Implant Dentistry! We appreciate the trust that you have placed in our office by selecting us as your partner in attaining optimal dental health. We believe that it is only through mutual understanding and clear, concise communication, that the most effective and long lasting treatment can be administered. Our goal is to protect your dental health and treat you in such a way that you will trust us with your specialized dental care for a lifetime. Enclosed you will find your patient registration, medical history, and financial policy forms. Please complete these forms and sign and dated where indicated prior to your first visit. A map with directions to our office is also enclosed for your convenience or for more information please visit our website at If you have insurance, please bring your insurance card and all pertinent information so that we may best assist you with the filing process. Please come prepared to be in our office for up to 2 hours for a thorough examination and consultation with your doctor. At your first visit you can expect to receive: an extensive clinical examination of the head, neck, and jaw joint, a screening for cancer of the oral soft tissues, and evaluation of the teeth, bone and gums. Necessary x-rays will be taken unless the required x-rays have been completed within the six months and records are available. Our team is dedicated to making each and every visit to our office a pleasant and enjoyable experience. Our patients always come first. You can be assured that we will create an individualized treatment plan to best suit your dental needs. We will also discuss both financial and time estimates for any needed treatment, before we proceed with any care. Please review the enclosed information. Should any questions arise before your appointment, please contact our office for assistance at Your partners in health, Darrin Rapoport, BDS, MSD Ralf F. Schuler, DR, MED, DENT, MSD Pacific Northwest Periodontics and Implant Dentistry
2 Financial Arrangements Policy At Pacific Northwest Periodontics and Implant Dentistry we take great pride in offering our patients a variety of treatment options that meet their unique needs and budgets. Treatment Options and Cost Estimates We will always provide you with an estimate of treatment costs related to the various treatment options, before any treatment is ever provided. As a courtesy we help file dental insurance claims. We will work with your insurance carriers in order to maximize your insurance reimbursement. However we never allow arbitrary insurance rules or limitations to affect your care, treatment options or the therapy we provide. Dental Insurance As a courtesy to you, our team will work with your dental insurance carriers to provide a good faith estimate of insurance coverage. We ask you to only pay the difference between the insurance estimate and our fee, at the time of service. Any overpayments will be refunded promptly to you when payment has been received form the insurance carrier. You will are always personally responsible for all fees you have agreed to and incurred in our office, irrespective of your insurance carriers limitations or denials. All balances are due within 30 days of the service. Payment and Financing Options As a courtesy we will assist you to find financing that fits your budget. We work with multiple health care financing companies and have multiple options to help meet your budget needs. For your convenience we accept the following methods of payment: Cash Checks MasterCard Visa Discover American Express Payment by Cash or Check We gladly accept cash or check for services rendered, and will provide a 5% discount when payment is received by cash or check. In the event that a check is returned for insufficient funds, a $50 administrative fee will be assessed and the 5% discount will be reversed. Alternative Financing Options Springstone Care Credit Springstone and CareCredit offer financing specifically for healthcare treatments and procedures, and can be used to pay for most out-of-pocket dental services, including cosmetic procedures and surgery. Our team can assist you in setting up no-interest payment plans with affordable monthly payments and no up-front costs. I, have read and understood the Financial Arrangement Policy and agree to the terms described therein. I understand that I will be personally responsible for any fees incurred at Pacific Northwest Periodontics and Implant Dentistry Signed Date 2
3 Acknowledgement of Privacy Rights/Form 3-B Pacific Northwest Periodontics Darrin A. Rapoport, DDS, MSD, PS Ralf F. Schuler, DR. MED. DENT, MSD 411 Strander Blvd. #302 Tukwila, WA My signature confirms that I have been informed that I have rights to privacy regarding my protected health information, and I have been given the opportunity to review this office's Notice of Privacy Practices as required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate treatment among health care providers who may be involved in my care. Obtain payment from third-party payers for my health care services. Conduct normal health care operations. I, have been offered the opportunity to read the Acknowledgement of Privacy Rights/Form 3-B. Signed Date Relationship to Patient (circle one): Self Parent Guardian Dependent family members also covered by this acknowledgement: For Office Use Only: We were unable to obtain the patient's written acknowledgement of our Notice of Privacy Rights due to the following reason: The patient refused to sign Communication barriers Emergency situation Other 3
4 Appointment Re-Scheduling, Cancellation and No-Show Policy We understand that there are times when you may need to cancel or re-schedule an appointment. We ask that if you need to do so, that you give us 48 hours notice (2 business days) for consultation and periodontal maintenance appointments and 3 business days (72 hours) for surgery appointments. This gives us the opportunity to accommodate another patient who is waiting for care. Therefore we remind you that there is a late cancellation/no-show charge of $100 for all consultation, follow up and periodontal maintenance (hygienist) appointments and $500 per hour for all surgery appointments. Your insurance carrier does not cover any cancellation fees. In order to provide excellent and consistent care we often schedule multiple appointments ahead. This way we are able to offer you appointment times that best fit your schedule. Please note that if you miss or need to cancel an appointment this may delay your treatment and affect your care. Appointment Confirmations and Reminders As a courtesy, we use an automated telephonic appointment confirmation system (HouseCalls ). This system will provide you with a timely reminder for upcoming non-surgical appointments. HouseCalls will call your designated telephone number prior to your scheduled appointment with an informative message to confirm the date and time of your visit. After you hear your appointment reminder message, HouseCalls will allow you to confirm your appointment, replay the message, or leave a message for our office. For example, Press 1 to confirm this appointment Press 3 to leave a message for our office Press 4 to replay the message. I, have read and understood the Appointment Re-Scheduling, Cancellation and No-Show Policy as well as the Appointment Confirmation and Reminder policy and agree to the terms described therein. I understand that I will be personally responsible for any cancellation incurred. Signed Date 4
5 Health History Name: (DOB: ) Date: Do you have or have you had any of the following? Please check "" or "". Heart Problems: High or Low Blood Pressure... Heart Murmur or Mitral Valve Prolapse... Artificial Valve, Pacemaker or Stent... Arteriosclerosis... Heart Attack or Angina Pectoris... Heart Medications or Nitroglycerin... Blood Problems: Easy Bruising... Abnormal Bleeding... Blood Thinners (Coumadin, Plavix or Aspirin).. Circulatory Problems... Hemophilia... Low Blood Sugar or Anemia... Respiratory Problems: Asthma, Emphysema or Tuberculosis... Tuberculosis... Chronic Bronchitis... Allergic Reactions: Aspirin, Acetaminophen, or Ibuprofen... Codeine or Other Narcotics... Dental Anesthetic... Sensitivity to Epinephrine (Vasoconstrictor)... Antibiotics (Penicillin or Other)... Sedatives (Valium) or Sleeping Pills... Latex (Allergy or Sensitivity)... Other: Diabetes... Any Physical Limitations... Hearing or Sight Disability... Glaucoma or Contact Lenses... Psychiatric Treatment... Depression or Anxiety Disorder... HIV or Aids... Hepatitis A, B or C... Sinus Troubles... Frequent or Severe Headaches... Fainting Spells, Seizures or Epilepsy... Liver or Kidney Issues... Drug or Alcohol Abuse Issues... Smoke or Chew Toba cco... Women Bone or Joint Problems Joint Replacement (Hip, Pins, Plates, etc)... Implants... Arthritis or Osteoporosis... Are you pregnant?... Taking Hormones or Oral Contraceptives?... Do you require "Premedication" with antibiotics prior to dental treatment?... Taking Bisphosphonates (Fosamax, Boniva)... Taking Corticosteroids... Cancer (Chemotherapy or Radiation)... Tumors or Benign Growths... Any Medications or Other Health Issues we should know about? Signed: 5
6 Your Health Care Provider Contact Information As part of our ongoing commitment to provide you with optimal periodontal treatment, please provide your Health Care Provider(s) contact information including your general/family care doctor and any of the applicable specialists shown below. Patient Name: Date of Birth: 1. General/Family Cardiology Oncology Endocrinology (Please check specialty) Physician Name: Clinic Name: Address: Telephone: City: State: Zip: 2. General/Family Cardiology Oncology Endocrinology (Please check specialty) Physician Name: Clinic Name: Address: Telephone: City: State: Zip: 3. General/Family Cardiology Oncology Endocrinology (Please check specialty) Physician Name: Clinic Name: Address: Telephone: City: State: Zip: Additional comments or information: 6
7 7
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
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
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
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.
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 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( )
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:
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
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
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283
Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283 Thank you for visiting Tempe Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient
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
Welcome to CitiDental
Date: Welcome to CitiDental Patient Information: Name D.O.B. SS# Address Apt Town State Zip Marital Status Home Phone Cell# Other Email Employer Work Phone EMERGENCY CONTACT: Name Phone Responsible Party:
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. Date of Birth Social Security # Primary Contact Number? Home Cell Work. Dental History. Reason for today s visit
Patient Information Michael G. Paat, DMD First name Middle Initial Last name Address City State ZIP Date of Birth Social Security # Home phone Cell phone Work phone Primary Contact Number? Home Cell Work
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
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
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 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
Welcome to Our Office - Tell Us About Yourself
General, Cosmetic & Implant Dentistry Welcome to Our Office - Tell Us About Yourself Name: Last First MI Title Address: City: State: Zip: SSN: Male Female DOB: Home Phone: Work Phone: Cell Phone: E-Mail:
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.
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,
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:
Today s Date: / / REASON FOR INITIAL VISIT: Whom may we thank for referring you? FIRST MI LAST PREFERRED
Durga Devarakonda, DMD PLLC DD Family Dentistry Family and General Dentistry 972-245-3395 PATIENT INFORMATION PLEASE COMPLETE THE FOLLOWING FORMS TO YOUR FULLEST KNOWLEDGE. DOING SO HELPS US BETTER CARE
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
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:
-Dr. Noreen Goldwire, DDS-
-- Patient Registration Name of Patient First Middle Last Nickname Birth Social Security # Person Responsible for Account Relationship to Patient Home Address Street City State Zip Email Address Home Phone
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
NEW PATIENT REGISTRATION
NEW PATIENT REGISTRATION Patient: Preferred Name: Last Name First Name Middle Initial Home #: Work #: Cell #: Email Address: The best way to contact me is through: Text Email Cell Home Work No preference
Jeremy C. Kiersz, DDS Rolla Family Dentistry 1701 E. 10 th Street Rolla, MO (573) Name. First MI Last Preferred Name
Patient Information Jeremy C. Kiersz, DDS Rolla Family Dentistry 1701 E. 10 th Street Rolla, MO 65401 (573) 364-1599 Today s Date (Please Print) Name First MI Last Preferred Name Birthdate Male Female
Welcome to Peter Fam Dentistry Tell Us About Yourself!
1 Welcome to Peter Fam Dentistry 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: E-mail Address: Employer:
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
Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Address
Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Home Phone Daytime/Work
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
NAME: PREFERRED NAME/NICKNAME: _ BIRTH DATE: SS#: MALE FEMALE ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE:
PATIENT INFORMATION NAME: PREFERRED NAME/NICKNAME: _ BIRTH DATE: SS#: MALE FEMALE ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: EMAIL: MAY WE CONTACT YOU BY TEXT? Y / N CHECK APPROPRIATE
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
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
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 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
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Welcome to VILLAGE DENTAL at Saxony - Tell us about yourself Name: Last First MI Title Preferred Name: Male Female Address: SSN: Date of Birth: Home Phone: Work Phone: Cell Phone: E-mail Address: Employer:
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:
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Georgia Knotek D.D.S. Personalized Dental Care
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Name Relationship Did you hear about us in any other way?
PATIENT INFORMATION Personal Information Patient s Name Today s Date Nickname/Preferred Name (if any) Birth date S.S. # - - Status (please circle) Child / Adult Single Married Divorced Widowed Parent s/spouse
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
375 East Main Street East Islip, NY Welcome!
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PATIENT REGISTRATION
Date: How did you hear about us? Name of previous dentist: PATIENT REGISTRATION PATIENT INFORMATION First Name: Last Name: Middle Initial Preferred Name: Birth Date: / / Age: Male Female Soc Sec: - - Address:
PATIENT 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
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
PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY)
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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
PATIENT REGISTRATION & HEALTH HISTORY FORM
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Patient Information. Dental Insurance. Phone Numbers
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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
SSN: DOB: Cell Phone: Home Phone: Work Phone: Preferred method of contact: Address: Employer: Occupation: Widowed. Divorced
2960 Professional Park Drive, Burlington, NC 27215 (336) 228-8159 office (336) 226-1936 fax www.alamancefamilydentistry.com info@alamancefamilydentistry.com Name: Last First MI Title Preferred Name: Male
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
PATIENT S NAME DATE OF BIRTH ADDRESS PHONE CELL PATIENT EMPLOYED BY PHONE BUSINESS ADDRESS PRESENT POSITION HOW LONG HELD
PATIENT REGISTRATION DATE PATIENT S NAME DATE OF BIRTH NAME OF SPOUSE STREET ADDRESS SINGLE MARRIED DIVORCED WIDOWED CITY STATE ZIP E-MAIL ADDRESS PHONE CELL PATIENT EMPLOYED BY PHONE BUSINESS ADDRESS
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
REGISTRATION FORM Section I: Patient Information. Date: Name: SSN: - - Date of Birth:
REGISTRATION FORM Section I: Patient Information Date: Name: SSN: - - Date of Birth: Address: City: State: Zip: Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Minor Single Married Widowed Separated Divorced
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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:
Joplin Periodontics & Implant Dentistry Humaira Y. Habib, D.D.S.
Today s Date: Preferred Name: Patient Information Last Name: First: Middle: Mr. Mrs. Birth Date: Miss. Ms. / / Is that your legal name? If not, what is your legal name? Age: Sex: Male or Female Address:
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.
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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
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
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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:
Responsible Party Information
Patient Information Date Male Female Married Single Divorced Separated Student Last Name First Name Middle Address City State Zip E-mail Address Social Security # Date of Birth Home # Work # Cell # Employer
Patient Name Birthdate Age
Patient Name Birthdate Age Marital Status: Single Married Divorced Widowed SS# DL# Home Address Zip Home Number ( ) Cell Phone ( ) Pager #( ). Email: Employer Name and Address Occupation Work # ( ) Person
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
Whom may we thank for referring you? About You. Name: I prefer to be called [] Male [] Female. Home Address: City State Zip
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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 or need assistance, please ask us we will be happy to
PATIENT REGISTRATION
PATIENT REGISTRATION First Name: Last Name: Middle Initial: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle
Drs. Ellis, Green and Jenkins
Drs. Ellis, Green and Jenkins WELCOME TO OUR PRACTICE Patient Information Today s : First Name: MI: Last Name: _ Birthdate: Age: SS#: _ Marital Status: Married Single Widowed Divorced Separated Address:
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.
HARTSELLE FAMILY DENTISTRY, LLC PATIENT REGISTRATION
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PATIENT REGISTRATION Today s Date:
FLYNN Dental Group Westside: 904-551-3083 PATIENT REGISTRATION Today s Date: Middleburg: 904-282-5025 Patient Name Sex: M F Birthdate Age Home Address City State Zip Please Your Circle One: Single Married
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
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 ( )
HARTSELLE FAMILY DENTISTRY, LLC PATIENT REGISTRATION
HARTSELLE FAMILY DENTISTRY, LLC 256-773-0800 PATIENT REGISTRATION Maggie McKelvey, D.M.D Ashley Holladay, D.M.D Patient Information First Name: Preferred: Last Name: Address: Address 2: City: State: Zip
Welcome to our practice! Our entire staff appreciates the opportunity you have given us to provide you with a pleasant experience while you are here.
Welcome to our practice! Our entire staff appreciates the opportunity you have given us to provide you with a pleasant experience while you are here. You have been given several forms to read and complete.
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. We re glad you re here.
Welcome. We re glad you re here. We know that going to the dentist may not be at the top of your to do list. But whether it s been six months or six years since your last visit, we re just glad you re
Patient Information. Health Information
PLEASE COMPLETE PRIOR TO YOUR APPOINTMENT. Return Via: Email:crosspatientcoordinator@verizon.net Fax: 301-662-4945 OR Bring to your appointment Patient Information Patient Name: Date: Last First MI Preferred
What to expect at your first visit
What to expect at your first visit Welcome'to'Grin.' To'save'you'time'at'your'4irst'visit,''complete'the'following'forms'before'you'arrive'for'your'appointment.''' ' ' ' The'typical'initial'visit'consists'of'the'following:'
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
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:
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
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
Patient, Pharmacy and Insurance Information Patient Information
Patient Name: Account #: Patient Code: Patient, Pharmacy and Insurance Information Patient Information Prefix: First Name: Middle Name: Last Name: Suffix: Street: Zip: City: State: Country: Preferred Phone
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
dental health associates, L.L.P.
JEFFREY G. BELL, D.D.S. GREGORY M. SWENSON, D.D.S. KIHO MA, D.D.S. MATTHEW OLMES, D.M.D susquehanna valley dental health associates, L.L.P. FINANCIAL AGREEMENT "Creating smiles is our business." Thank
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
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
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,
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:
Your visit with us will consist of meeting our team, taking a tour of our office, and a comprehensive exam with Dr. Koch.
Welcome to our family of fine patients and thank you for selecting us as your personal dental care team. We will always strive to make your relationship with us as pleasant and rewarding as possible. Your
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?