Patient Registration
|
|
- Vincent Hensley
- 6 years ago
- Views:
Transcription
1 Patient Registration Date: First Name Last Name Middle Initial Preferred Name Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers License Sex Marital Status Employer Responsible Party (if someone other than the patient) First Name Last Name Middle Initial Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers License In Case of Emergency Contact Name Relationship Home Phone Cell Phone Work Phone Ext Primary Insurance Information Name of Insured Relationship Insured Social Security Insured Birth Date Insured ID # (usually found on dental insurance card) Employer Insurance Company Group # Phone # Address
2 Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician s care now? Y / N If yes explain Have you ever been hospitalized? Y / N Have you ever had a serious neck injury? Y / N Are you taking any medications, pills or drugs? Y / N Are you on a special diet? Y / N Do you use controlled substances? Y / N Women: Are you pregnant/trying to get pregnant? Taking Oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetic Other: Do you have, or have you had any of the following? AIDS/HIV Positive Y / N Cortizone Medicine Y / N Hemophelia Y / N Renal Dialysis Y / N Alzheimer's Disease Y / N Diabetes Y / N Hepatitis A Y / N Rheumatic Fever Y / N Anaphylaxis Y / N Drug Addiction Y / N Hepatitis B or C Y / N Rheumatism Y / N Anemia Y / N Easily Winded Y / N Herpes (mouth) Y / N Scarlet Fever Y / N Angina Y / N Emphysema Y / N High Blood Pressure Y / N Shingles Y / N Arthritis/ Gout Y / N Epilepsy or Seizures Y / N Hives or Rash Y / N Sickle Cell Anemia Y / N Artificial Joint Y / N Excessive Bleeding Y / N Hypoglycemia Y / N Sinus Trouble Y / N Asthma Y / N Excessive Thirst Y / N Irregular Heartbeat Y / N Spina Bifida Y / N Artificial Heart Valve Y / N Fainting Spells Y / N Kidney Problems Y / N Stomach/Intestinal Disease Y / N Blood Disease Y / N Frequent Coughs Y / N Leukemia Y / N Stroke Y / N Blood Transfusion Y / N Frequent Diarrhea Y / N Liver Disease Y / N Swelling of Limbs Y / N Breathing Problems Y / N Frequent Headaches Y / N Low Blood Pressure Y / N Thyroid Disease Y / N Bruise Easily Y / N Genital Herpes Y / N Lung Disease Y / N Tonsilitis Y / N Cancer Y / N Glaucoma Y / N Mitral Valve Prolapse Y / N Tuberculosis Y / N Chemotherapy Y / N Hay Fever Y / N Pain in Jaw Joints Y / N Tumors or Growths Y / N Chest Pains Y / N Heart Attack / Failure Y / N Parathyroid Disease Y / N Ulcers Y / N Cold Sores/Fever Blisters Y / N Heart Murmur Y / N Psychiatric Care Y / N Venereal Disease Y / N Congenital Heart Disorder Y / N Heart Pace Maker Y / N Radiation Treatments Y / N Yellow Jaundice Y / N Convulsions Y / N Heart Trouble /Disease Y / N Recent Weight Loss Y / N Sleep Apnea/Snoring Y / N Have you ever had any serious illness not listed above? If yes, please explain: Do you have any trouble sleeping or are you chronically tired throughout the day? If yes, please explain:
3 Dental History Reason for today s visit: Are you in pain? Do you smoke/chew tobacco? If yes, how long? Former Dentist City/State Date of Last visit Date of Last X-rays Whom may we thank for referring you? Who is your favorite Musician/ Band? Are you happy with your teeth s appearance? Are you happy with the function of your teeth? Is there anything you would change about your teeth? Have you ever had a bad dental experience? If yes, please describe: Do you have, or have you ever had any of the following? Bad Breath Y / N Bleeding Gums Y / N Blisters on/around Mouth Y / N Burning Sensation on Tongue Y / N Cigarette, Cigar Smoking Y / N Chew on one side of mouth Y / N Dry Mouth Y / N Fingernail Biting Y / N Foreign Objects Y / N Lip or Cheek Biting Y / N Loose Teeth Y / N Broken Fillings Y / N Mouth Breathing Y / N Mouth Pain, Brushing Y / N Orthodontic Treatment Y / N Pain Around Ear Y / N Periodontal Treatment Y / N Sores/Growths in Mouth Y / N If answering Yes to any of the following please explain: Food Collection Between Teeth Y / N Grinding Teeth Y / N Gums Swollen or Tender Y / N Jaw Pain or Tiredness Y / N Sensitivity to Heat Y / N Sensitivity to Cold Y / N Sensitivity to Sweets Y / N Sensitivity when Biting Y / N How often do you floss? How often do you brush? To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient s) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian Date
4 Authorization and Consent Form Patient Name Date of Birth Date of Visit Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. A copy of the Notice of Privacy Practices accompanies this consent at your request. You have the right to request that we restrict how protected health and dental information about you is used or disclosed for treatment, payment, or dental care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health and dental information about you for treatment, payment and health care operations. Your information will be disclosed to your insurance company for billing purposes. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your consent. In the event a family member or caregiver attends my office visit and remains in the operatory at the time of my evaluation and/or treatment, I give Dr. Spear, or his employees, my permission to discuss freely my condition, treatment or diagnosis. May we mail dental related information to your home? Yes / No Any and all dental information can be released to the following: 1. Relationship 2. Relationship 3. Relationship Assignment of Benefits: I hereby authorize all insurance companies to pay directly to Brent Spear, D.D.S. I understand that this order does not relieve me of my obligation to pay the account. Also, any balance that is not covered or paid by the insurance company is my responsibility. Patient/Guardian Signature: Date Financial Responsibility Agreement INSURANCE: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any dental service or visit, examinations, x-rays, treatment or any other service performed by the dentist or the dentist s staff. I understand and agree it is my responsibility and not the responsibility of the dentist or dentist s staff to know if my insurance will pay for my dental service or visit. I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, and out-of-network amount. I understand and agree it is my responsibility to know if the dentist is a contracted in-network provider recognized by my insurance company or plan. If the dentist I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible and make full payment. NO INSURANCE: I understand and agree that I will be financially responsible for any and all charges for dental services performed by the dentist or her staff. I understand and agree it is my responsibility to pay for all dental charges at the time of service. I understand and agree that it is not the policy of the office of Brent Spear, D.D.S. to offer payment plans for any dental services. I understand and agree in the event that my account is turned over to a collection agency, I will be held accountable for any and all service fees incurred. Patient/Guardian Signature: Patient/ Guardian Name Printed: Date Date
5 We would like to give you a new and simpler way to be reminded about your appointments. Our office is introducing a patient login portal that offers you the convenience of 24/7 access to your account information as well as the ability to choose how you would prefer to be contacted by us. If you choose the option, you will be sent log in information via . The log in can be accessed on our website: Please let us help you get started! How would you like to be notified for your appointments? (Please check appropriate space and provide address or number as needed after the options.) Text message (cell) Phone call Appointments and Cancellations When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved room to another patient who would like it. There is a charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in loss of future appointment privileges. We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. By signing, you acknowledge and agree to the above appointment cancellation policy. Signature of Patient Date
PATIENT REGISTRATION
TIME 2:51 PM DATE 6/26/2013 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
More informationPatient: Last name: First Name: DOB: Social Security Number: Relationship Status: Sex: F/M
PATIENT INFORMATION Patient: Last name: First Name: Relationship Status: Sex: F/M Cell Phone: Home Phone: Employer Name: E-mail: How did you hear about us? Parent/Guardian Information (REQUIRED IF PATIENT
More informationPATIENT 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:
More informationPATIENT 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
More informationPatient Information. Dental Insurance. Phone Numbers
Our goal is to provide you with the safest, most comfortable experience a dental office can provide. If you have any questions please do not hesitate to call us. Patient Information Date: SS/Patient ID:
More informationDavid 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
More informationPatient 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
More informationPatient Registration
Patient Registration ID: Chart ID: First Name: Last Name: Middle Initial: Patient is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient) First Name: Last
More informationJeffrey 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:
More informationPatient 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
More informationPATIENT 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
More informationWELCOME! 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:
More informationPATIENT REGISTRATION
PATIENT REGISTRATION ID: Chart ID: First Name: Last Name: Middle Initial: Patient is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient) First Name: Last
More informationDO 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?
More informationPERSONAL HISTORY. Spouse s Name:
PERSONAL HISTORY Date: Patient Name: Address: Zip Code: Sex: Marital Status (circle one): S M D W Sep Spouse s Name: Date of Birth: / / Social Security Number: - - Employer: Home Phone: Cellular Phone:
More informationDental 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
More informationFirewheel Smiles corn
Firewheel Smiles corn Patient Name: 4502 River Oaks Pkwy Suite 200, Garland, TX 75044 (214) 703-5490 Registration and Health History Patient Information Today's Reason for this visit: Patient's Name: DOB:
More informationPatient 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
More informationPatient 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
More informationTodd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics
Todd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics 3048 E Baseline Rd. Ste. 112 Mesa, Arizona 85234 Telephone: 480-558-4500 Fax: 480-827-9703 PATIENT INFORMATION Today's Date Name Social Security
More informationPATIENT FIRST NAME LAST NAME MI FIRST NAME LAST NAME MI ADDRESS CITY, STATE, ZIP HOME PHONE WORK # CELL# BIRTH DATE SOC SEC # - - DRIVERS LIC #
PATIENT REGISTRATION PATIENT FIRST NAME LAST NAME MI PREFERRED NAME PATIENT IS: POLICY HOLDER RESPONSIBLE PARTY RESPONSIBILE PARTY (If someone other than the patient) FIRST NAME LAST NAME MI ADDRESS CITY,
More informationWelcome to Metropolitan Dental Care
Welcome to Metropolitan Dental Care Personal Information Date_ First Name Last NameMiddle Initial Preferred Name Address City, State, Zip Home Phone Work Phone_Cell Phone Male Female Minor Single Married
More informationWelcomes You! Patient Information. Name: Preferred name: Male Female (Last) (First) (Mi) Home Address: (Street) (City) (State) (Zip)
Welcomes You! Patient Information Today s Date: E-mail Address: I would like to receive correspondence via: e-mail text phone Name: Preferred name: Male Female (Last) (First) (Mi) Birthdate: / / Age: Social
More informationPatient Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist.
Patient Profile First Name Last Name Pref. Name Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Emergency
More informationWELCOME 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
More informationWELCOME TO INFINITY DENTAL EXCELLENCE
WELCOME TO INFINITY DENTAL EXCELLENCE Today s : Email Address: Name: I prefer to be called: o Male o Female Last First MI Mr. Mrs. Ms. Dr. Birthdate: / / Age: Social Security #: o Single o Married o Divorced
More informationKathryn E. Boehly, DMD & Associates 6290 Linton Boulevard, Building IV, Suite 202, Delray Beach, Florida 33484
Kathryn E. Boehly, DMD & Associates 6290 Linton Boulevard, Building IV, Suite 202, Delray Beach, Florida 33484 Phone: (561) 381-4744 Fax: (561) 381-4743 reception@drboehly.com www.drkathrynboehly.com PATIENT
More informationPatient Registration
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: Patient is: Policy Holder Responsible Party Address: City State/Zip Home Phone: Cell Phone: Work Phone: Sex: Male Female Marital
More informationFINANCIAL POLICY. Policy Regarding Minor Children
FINANCIAL POLICY We are committed to providing you and your family with the best possible care. In order to achieve these goals, we need your assistance and your understanding of our policy regarding payment
More informationPatient Registration
Patient Registration Patient Name: Preferred Name:_ Birth :_ Social Security #:_ Address: Street Unit # (if applicable) City State Zip Code Home Phone #: Cell Phone #: Email: Preferred method of contact?
More informationPatient registration. MyIdealDental.com. Primary insurance information. Secondary insurance information
Patient registration Patient ID Chart ID Medicaid ID Employer ID First Name Last Name Member ID Carrier ID Preferred Name Middle Initial Patient is: Primary policy holder Responsible Party is: Primary
More informationNew Patient Paperwork
New Patient Paperwork Patient Information: Patient Name: DOB: Home Address: City: State: Zip Code: Home #: Cell #: E-Mail: @. Would you like to receive text messages and/or emails as appointment reminders?
More informationPatient Profile. Appointment Preference. Referral Profile. Insurance Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec.
Patient Profile First Name Last Name Pref. Name of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Phone # Emergency
More informationPreferred Name: First Name: Last Name: Middle Initial: Work Phone: Ext: Cellular:
TIME PATIENT REGISTRATION DATE ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party ( if someone other than the patient ) Last Name: Preferred Name: Middle Initial: First
More informationResponsible Party (if someone other than the patient)
PATIENT REGISTRATION ID First Name Last Name Chart ID Middle Initial Patient is Policy Holder Responsible Party Preferred Name Responsible Party (if someone other than the patient) First Name Last Name
More informationPATIENT 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
More informationPATIENT REGISTRATION
TIME 10:44 AM DATE 7/12/2011 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
More informationMartinDental. Welcome to
Welcome to MartinDental We want you to have the most relaxing and comfortable experience possible with us. Help us get to know you by answering the following questions. Thank you! When I think about coming
More informationWhat 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:'
More informationStreet Address City State Zip. Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor Separated Divorced
PATIENT REGISTRATION AND MEDICAL HISTORY First Name: Last Name: Middle Initial: Preferred Name: Street Address City State Zip Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor
More informationSpouse 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
More informationInsurance Company: Group No.: Insurance address: City:
Patient Information First Name: Last Name: Middle Initial: Preferred Name: Birth Date: / / Age: Sex: Male Female Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Preferred Phone# for
More informationWelcome 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:
More informationHARTSELLE 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: Last Name: Address: Address 2: City: State: Zip Code: Home
More informationHARTSELLE 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
More informationL. JASON PAYNE, D.M.D., P.C.
L. JASON PAYNE, D.M.D., P.C. PATIENT REGISTRATION First Name: Last Name: Middle Initial: Patient Is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient)
More information9521 US Hwy 290 West, Suite 103 Austin, TX (512) PATIENT INFORMATION
9521 US Hwy 290 West, Suite 103 Austin, TX 78737 (512) 888-9453 PATIENT INFORMATION Please Circle Title: Dr. Mr. Mrs. Miss Name: First M Last I prefer to be called: Male Female Birthdate: Age: _ SSN #
More informationWelcome. 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
More informationPATIENT 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:
More informationWhite Rock Dental. Periodontal Treatment (Deep Clean) Bleeding Gums. Sensitivity of your teeth to heat or cold Clicking/Popping jaw joints
Patient Information: (All Fields Required) Date: Legal First Name: Last: MI: Preferred Name: Date of birth: SSN: Address: Apt? No Yes: Apt #: City/State: Zip: Email: Home Ph: Cell: Prefer Contact By: Call
More informationMacon County Health Department Dental Clinic
Macon County Health Department Dental Clinic PATIENT REGISTRATION ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name:
More informationJennifer Q. Le, DMD, D-ABDSM, CPCC, ACC Diplomate of American Board of Dental Sleep Medicine. Dental Patient Registration
Dental Patient Registration Patient Information First Name: Middle: Last: How did you hear about us? Preferred Name: Address: City, State, Zip: Home Phone: Work Phone: Ext: Cellular: Email address: By
More informationDental 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.
More informationFirst Name Last Name Middle Initial. City State ZIP. Birth Date: SS#: Driver s Lic#: State:
DATE PATIENT ACCOUNT NO PatientRegistration PATIENT S FULL NAME Policy Holder Responsible Party RESPONSIBLE PARTY (if someone other than the patient) First Name Last Name Middle Initial City State ZIP
More informationtvcle EXPRESSIONS Phone: (727) 78-SMILE Looking forward to seeing you!
I DR. LYNDSAY H. MCCASLIN Cosmetic & Family Dentistry Phone: (727) 78-SMILE 727-787-6453 oo so U. af c =3 < 2 Thank you for choosing our dental practice. We look forward to meeting you, and giving you
More informationPATIENT 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
More informationPatient Registration Form
Patient Registration Form Patient Name: Date of Birth: SS #: Driver s License: Address: City/State/Zip: Name of Insured: Insured SS#: Insured DOB: Relation to Patient: Spouse Parent Other Employer: Position
More informationWELCOME TO PRAIRIE GARDEN DENTAL. Responsible Party/Primary Insurance Holder If different from above
WELCOME TO PRAIRIE GARDEN DENTAL Patient Information Date Name Preferred Name Birthdate Social Security # Female Single Married Divorced Widowed Separated Other Home Address Employer Occupation Home Phone
More informationPATIENT 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
More informationDENTAL REGISTRATION AND HISTORY
DENTAL REGISTRATION AND HISTORY 1. PATIENT INFORMATION Date Patient Name Last Name First Name Middle Initial Address E-mail City State Zip Sex M F Age Birth date Married Widowed Single Minor Separated
More informationPatient Information Sheet Date: Chart ID: Whom may we thank for referring you?
Patient Information Sheet Date: Chart ID: Whom may we thank for referring you? First Name: Driver License: Last Name: SSN: Middle Initial: Preferred Name: E-mail: Gender: o Male o Female Please circle:
More informationYour 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
More informationDrs. Helsby and McMann 2100 AlomaAve., Suite 200 Winter Park, Fl
2100 AlomaAve., Suite 200 Winter Park, Fl. 32792 PATIENT REGISTRATION First Name: Preferred Name: Birth : City, State, Zip: Home Phone: _ Drivers License # Last Name: Middle Initial Patient is: Policyholder
More informationWelcome. 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)
More informationPatient Registration Montgomery Dental Arts
Patient Registration Montgomery Dental Arts Patient s First Name: Middle: Last: Preferred Name: of Birth: Patient is covered by dental insurance: / Patient is the person responsible for payment: / Address:
More informationWelcome. Firas Salhi, DDS Terrylynn Tennant, DMD, AADSM
Welcome Firas Salhi, DDS Terrylynn Tennant, DMD, AADSM A very warm welcome to you! The entire team would like to thank you for selecting our office to care for your dental needs. Our goals are to provide
More informationPARENT/GUARDIAN INFORMATION
Ahmadi & Alvand, DDS, PA General, Cosmetic and Implant Dentistry PATIENT INFORMATION Full Name Preferred Name Address City State Zip code Home Phone Number Work Cell phone Language Sex Marital Status:
More informationPlease do not hesitate to call us if we can answer any questions about these forms or your first visit with us.
Welcome to our Practice! We are delighted that you have selected our office for your dental care. To assist us in providing you with excellent service, please take a few minutes to print the enclosed forms
More informationPATIENT 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
More informationREGISTRATION FORM HISTORY Patient Information
REGISTRATION FORM HISTORY Patient Information Name: of Birth SS # Home phone # ( ) Cell phone # ( ) Address Apt. # City State Zip Driver s License # State Email Address: Check Appropriate Box: Minor Single
More informationWhat 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
More informationToday's Date: (MM/DD/YEAR) / /20
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
More informationPLEASE 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
More informationAddress City State Zip
6500 N Mopac Expy #2204, Austin, TX 78731 (512) 458-3111 Patient Registration Today s Date Patient Name Driver s License How did you hear about Austin Smiles? Is this visit related to a Routine Exam &
More informationPATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address:
More informationTaylor 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
More informationNew 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:
More information117 FLORAL VALE BLVD, YARDLEY, PA PHONE: FAX: PATIENT INFORMATION
117 FLORAL VALE BLVD, YARDLEY, PA -19067 EMAIL: radiantsmiles2009@yahoo.com PHONE: 215-860-4600 FAX:215-860-1455 PATIENT INFORMATION Patient s Name: (Last) (First) (MI) Address: (Street/Apt.) (City) (St)
More informationReferred By Phone. Pharmacy Name, Location & Phone #
3150 E. 41 st St., Suite 131, Wellington Square Building Tulsa, Ok 74105 (918) 749-1639 Fax (918) 749-0416 info@midtownsmilestulsa.com Patient Information Patient Name Address City State Zip Date of Birth
More informationWELCOME 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,
More informationPATIENT REGISTRATION
PATIENT REGISTRATION Patient Name: Last Name: Middle Initial: Preferred Name: Referred By: Patient is: Responsible Party Policy Holder Patient Information: Address: City, State, Zip: Home Phone: Work Phone:
More informationGeorgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
More informationPatient Information. Dental Insurance. Emergency Contact
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we ll be glad to help you. Patient Information Date Patient
More informationPatient Registration
Patient Registration Patient s Name: Date of Birth: Mailing Address: Social Security #:_ Primary Phone #: Secondary Phone #: Employer: Work Phone: _ Emergency Contact: Emergency Contact Phone #: Person
More informationPATIENT 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
More informationBoard Certified in Periodontics Board Certified in Oral Medicine Fellowship in the Academy ofgeneral Dentistry. Social Security
Implants (\J PERIODONTICS Oral Medicine ~ George Quintero, D.D.S., P.C. Board Certified in Periodontics Board Certified in Oral Medicine Fellowship in the Academy ofgeneral Dentistry ~ Patient Information
More informationWorthington 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,
More informationDENTAL REGISTRATION AND HEALTH HISTORY
DENTAL REGISTRATION AND HEALTH HISTORY PATIENT INFORMATION Soc. Security #/Patient ID #: Patient Name: Gender: Date of Birth: Age: E-mail: Phone (Home): (Work): Ext: (Cell): Address: City: State: Zip:
More informationPATIENT 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
More informationDr. Víctor Vergara DMD P.A Livingston Rd, Bldg # 100, Ste. #106, Naples, FL Fax PATIENT HEALTH RECORD
! Dr. Víctor Vergara DMD P.A. 239-263-0912 13180 Livingston Rd, Bldg # 100, Ste. #106, Naples, FL 34109 Fax 239-263-0925 PATIENT HEALTH RECORD PATIENT INFORMATION Date (Month/Day/Year) / / DATE OF BIRTH
More informationLasting 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:
More informationConsent for Treatment
Consent for Treatment 1. I hereby authorize doctor or designated staff to take radiographs, study models, photographs, and other diagnostic aids appropriate by doctor to make a thorough diagnosis of dental
More informationTfeTaCma DentaQ LXJZ Michael DePalma, DDS Errin DePalma, DDS. 500 Franklin Avenue, Unit 3 Berlin, MD , P
Conf i r m appoi nt mentby : Emai l Phone T ex t SMILE SURVEY YES NO Do you like to smile and show your teeth? Are you happy with the way your teeth look? Do you have unsightly crowns or fillings? Are
More informationWELCOME TO THE PROVINCES DENTAL CARE
WELCOME TO THE PROVINCES DENTAL CARE Name Nickname Address Unit# Birth Date Age Sex City State Zip Single Married Widowed Other Home Phone Social Security # Work Phone Employer Cell Phone Occupation E-Mail
More informationNew 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:
More informationWelcome to Family Tree Dental Care Midway Rd., Ste 106A Farmers Branch, TX 75244
Patient Information: Patient s Name: Address: City, Zip Code: Email address: Sex: M/F SSN: Date of Birth: Age: Marital Status: Home Phone: Cell Phone: Work Phone: Responsible for Account/Subscriber/Guardian
More informationPrimary Insurance. Insurance Group # Insurance Phone # Please present your Insurance Card and Driver's License to the receptionist to be photocopied*
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
More informationPatient Registration/Financial Policy
Patient Registration/Financial Policy Date: Patient Information First Name: Last Name: Middle Initial: Preferred Name: Parent/Legal Guardian(s) if under the age of 18: Address: City: State: Zip: Home Phone:
More informationBozart 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
More informationFort Wayne Dental Group
Fort Wayne Dental Group 7202 Engle road * Fort Wayne, Indiana 46804 * (260) 432-3459 PATIENT INFORMATION DATE: NAME: Married Single Male Female LAST FIRST M ADDRESS: STREET APT.# CITY STATE ZIP BIRTHDATE:
More information