You will also discuss with the doctor several anesthesia options for your comfort:
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1 Welcome to Northeast Oral & Maxillofacial Surgery! We appreciate the opportunity to be of service to you. Please complete the enclosed Patient Information and Medical History forms in black or blue ink only. You will need to bring the completed forms along with your current Insurance card and photo ID to your next scheduled appointment. Note: the Patient Information form may also be completed on-line 48 hours prior to your appointment but it is recommended that you print out a copy and bring it with you, as well. You are encouraged to schedule a preoperative consultation to discuss your planned procedure. We will also discuss your health history and/or medications you may be taking, especially if you have experienced any of the following conditions: Serious health problems Artificial heart valve Dialysis Diabetes Artificial hip or knee joint Latex allergy Heart murmur Take blood thinners Bleeding disorders Recent use of diet pills You will also discuss with the doctor several anesthesia options for your comfort: Local anesthesia - Numbing injections are given in the appropriate area(s). It is not necessary to change your eating habits before your appointment. Please take any prescription medications as you normally would. If you are pregnant, then local anesthesia is recommended. Nitrous oxide and local anesthesia - Nitrous oxide gas is administered to produce a relaxed, awake state. Numbing injections are then given. It is not necessary to change your eating habits before your appointment unless you are instructed otherwise. Intravenous anesthesia - Intravenous (IV) medications are given to produce a semiconscious or unconscious condition. The numbing injections and surgery are accomplished while you sleep. Following the surgery, you should plan to rest at home for the remainder of the day. Please note the following if you prefer IV anesthesia: You must not eat or drink for at least six hours before your appointment. You may take prescription medications with a small amount of water. You will need to have a responsible adult with you to drive you home. This is very important! Your escort must be present before and during your procedure, and should plan to stay with you the remainder of that day. (Please continue on back)
2 You should wear comfortable, loose-fitting clothing. Short sleeves are desirable. Remove all jewelry before your appointment. If you wear contact lenses, we recommend that you remove them and wear your eyeglasses instead. Remove nail polish and artificial nails from at least the index finger of each hand before your appointment. This is very important for monitoring purposes during the procedure. IMPORTANT: It is our office policy that parents, spouses or other family members are not allowed in the room during the patient s surgical procedure and must remain in the reception area during their surgery. Thank you again for calling us for your oral surgery needs. It is our goal to provide you only the highest quality care in a comfortable and safe atmosphere. If you have any questions that haven t been answered in this letter, we will be happy to address them at your consultation. Sincerely, Dr. Brent T. Garrison, Dr. Corbin G. Partridge, Dr. Patrick S. Kelly and the Staff For more information, visit our website at Learn about our office and the surgical procedures and other services our office provides. Find information on the preoperative consultation, scheduling, financial options, insurance, anesthesia options, and preoperative and post surgical instructions. (See the Patient Information link.) Complete your Patient History form on-line. Please complete and submit the form at least 48 hours before your appointment. We recommend you bring a print-out of the pages you submitted on-line when you visit the office. Locate our office. Our website has a link to provide driving directions from any location, i.e. your home or office address. 8-09
3 Northeast Oral & Maxillofacial Surgery Patient Information page 1 Mr. Mrs. Ms. Miss Dr. First MI Last Nickname Address City/State Zip Home Work Cell SS# - - Sex: Male Female Age Birthdate / / Single Married Widowed Divorced Employer Occupation Your Dentist Physician Orthodontist Who referred you to our office? Dentist Physician Orthodontist Friend Other Have you or any family member been a patient at this office before? no yes If yes, what year? Who Relationship Is patient a full-time student? no yes Name of School Emergency Contact Relationship Daytime Phone Is someone other than the patient responsible for this account? no yes If yes, please complete the following information: Name DOB / / SSN# - - Home Phone Address City/State Zip Relationship to Patient Occupation Work Phone PRIMARY INSURANCE COVERAGE INFORMATION PRIMARY DENTAL INSURANCE (List secondary dental insurance on page 2.) PRIMARY MEDICAL INSURANCE Insurance Co. Name Address Phone Name of Insured DOB / / Insured Daytime Phone (List secondary medical insurance on page 2.) I understand in signing this statement that I am financially responsible to Northeast Oral & Maxillofacial Surgery (NEOMS) for all fees incurred and all costs of collection, including but not limited to service, collection, collection agency, and attorney charges, if necessary. I hereby authorize the insured s insurance company to pay directly to NEOMS any and all of the benefits otherwise payable to me. I further authorize the release of health care information for the purpose of evaluating and administering claims for benefits. Patient Signature or Parent/Guardian if Patient is a Minor Printed Name Date
4 Northeast Oral & Maxillofacial Surgery Patient Information page 2 First MI Last Nickname SECONDARY INSURANCE COVERAGE INFORMATION SECONARY DENTAL INSURANCE SECONDARY MEDICAL INSURANCE AUTOMOBILE ACCIDENT WORKERS COMPENSATION Accident/Workers Compensation Information (Please describe how your accident occurred.)
5 Medical History Patient Name: First MI Last Nickname Reason for today s office visit: Are you in good health? Height Weight Age Are you under the care of a physician? If yes, date of last visit For what were you being treated? Have you ever had any illness or been hospitalized? If yes, please explain: Yes No Notes Please indicate if you have had any of the following conditions: Yes No Notes Yes No Notes Heart Disease Radiation Treatment Chest Pains Anemia Heart Murmur Bleeding Problems Mitral Valve Prolapse Stomach Ulcers Rheumatic Fever HIV or AIDS High Blood Pressure Tumors/Growths Artificial Heart Valve Chemotherapy Pacemaker Hepatitis or Jaundice Stroke Diabetes Bruising Thyroid Disease Glaucoma Kidney Disease Fainting Spells Arthritis Chronic Fatigue Artificial Joints Asthma Seizures (Epilepsy) Lung Disease Cancer Tuberculosis Swollen Ankles Hay Fever/Sinus Liver Disease Shortness of Breath Alcohol/Drug Abuse Snoring Delayed Healing Are you allergic to anything (ie. latex, tape, antibiotics or pain medications)? Are you currently taking any drugs or medications? Have you ever had any adverse reaction to an anesthetic? Have you ever had or been treated for clicking or pain in your jaw joint (TMJ)? Have you ever had any unusual problems with previous dental work? Is this visit a result of an accident? Do you smoke? Have you ever taken diet pills (ie. Fen-Phen or Redux)? Are you taking any herbal medications (ie. St. John s Wort)? Women: Are you taking birth control pills? Are you pregnant? Are you nursing? Do you have any other conditions or problems we should know about prior to treatment? Do you have any history of family diseases that we should know about? Yes No Notes I hereby certify that the above information is accurate and complete to the best of my knowledge. Patient or Parent/Guardian Signature Date
6 Northeast Oral & Maxillofacial Surgery Statement of Financial Responsibility We understand that the financial aspects of healthcare can be difficult to understand and confusing. Our office will try to do everything we can to help you. If you provide us accurate and current insurance information, we will be happy to file your charges with your primary and secondary insurance companies. We ask that you bring proof of coverage (insurance ID card or insurance forms) at the time of your appointment. These documents will provide essential information that will help us determine the special requirements of your insurance plan, such as how often you may be treated and who may provide treatment to you and any family members covered by your plan. Please take time to review the following checklist that will help you provide us all of the necessary information at your appointment. If you have health insurance: o Determine whether or not Dr. Garrison, Dr. Partridge, or Dr. Kelly is a particiating provider of your insurance plan. If your insurance company requires a referral from your dentist or physician, please bring a copy of the referral with you to your appointment. Check if your insurance plan requires prior authorization as a requirement for benefits to be paid. If so, you may need to contact your insurance company prior to your appointment. If your insurance coverage requires a co-pay at the time of service, please be prepared to pay that amount on the day of your appointment. You may call our office if you would like an estimate of the payment that will be due the day of your appointment. As a courtesy, we will submit the initial claim to your insurance company for services we provide you. You will receive a statement as long as your account has a balance unless you are a Medicare/Medicaid patient, Worker s Comp patient, or an automobile accident patient. You will be responsible for all charges your insurance company does not cover due to unpaid deductibles, coinsurance, or non-covered services. If you do not have insurance coverage or if non-covered services are provided: Please call our office to obtain an estimate of charges for the services you plan to have done at your appointment. We accept cash, checks, and Visa, Mastercard, Discover & Care Credit. I have read and understand the statement of financial responsibility above and agree to accept financial responsibility for all services provided by Dr. Garrison, Dr. Partridge, or Dr. Kelly as described. Patient s (or Legal Guardian s) Signature Printed Name Date Revised 2-13
7 Brent T. Garrison, D.D.S., M.S.D. Corbin G. Partridge, D.M.D. Patrick S. Kelly, D.D.S. Northeast Oral & Maxillofacial Surgery 9860 Westpoint Drive, Suite 100. Indianapolis, IN Phone N Directions from the south: Take I-69 north, exit at 96th St. and turn left on 96th St. After you turn, immediately move to the far right lane and go to the second stop light and turn right (north) on Hague Rd., located on the WEST SIDE of I-69. Go to Westpoint Dr. and turn right. (Look for the Crosspoint complex entrance on the right, past the Spring Hill Suites Marriott.) Just around the curve, the office is on the left, located on the east side of the building in the center of the office complex, facing Westpoint Dr. N Directions from the north: Take I-69 south, exit at 96th St. and turn right on 96th St. Stay in the right lane and turn right (north) on Hague Rd., located on the WEST SIDE of I-69. Go to Westpoint Dr. and turn right. (Look for the Crosspoint complex entrance on the right, past the Spring Hill Suites Marriott.) Just around the curve, the office is on the left, located on the east side of the building in the center of the office complex, facing Westpoint Dr. 2-08
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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:
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print)
Page 1 of 6 Today s date: Patient s Last name: First name: Middle name: Sex: M F MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print) PATIENT INFORMATION Mr. Mrs. Miss Ms. Birth Date: Age:
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
YOUR FIRST APPOINTMENT IS ON AT.
DWAYNE KIM MARTIN, D.D.S., M.S. HILLTOP PROFESSIONAL BUILDING 1855 SAN MIGUEL DRIVE, SUITE 21 PERIODONTICS AND DENTAL IMPLANTS WALNUT CREEK, CALIFORNIA 94596 (925) 932-1422 FAX (925) 932-2020 Email: martinperio@sbcglobal.net
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
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 any questions we ll be glad to help you. We look forward to
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
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History
AristidisPontikas, 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 Cell Phone Home
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
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
Madison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
Today's Date: PRIMARY INSURANCE Name: Subscriber's Name:
The following questions are about the insurance subscriber(s): Today's Date: PRIMARY INSURANCE Name: Subscriber's Name: Preferred Name: Date of Birth: Gender: Single Married Child Other Phone Number: Date
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
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
5414 Sunrise Blvd, Ste D Citrus Heights, CA p:
5414 Sunrise Blvd, Ste D Citrus Heights, CA 95610 p: 916.251.9909 Today s Patient information: Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Street Apt. Home
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.
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
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
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)
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
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
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:
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. Date: Patient Name: Social Security #: Address:
WELCOME PATIENT INFORMATION: Date: Patient Name: Social Security #: Address: Email: Sex: Male Female Age: Birthdate: Married Separated Widowed Single Divorced Minor Partnered for years Patient Employer/School:
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