WELCOME TO THE PROVINCES DENTAL CARE
|
|
|
- Shannon Hensley
- 5 years ago
- Views:
Transcription
1 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 Who referred you to our office? (We would like to thank them!) Person to notify in case of an emergency Their Phone Name of your Primary Dental Insurance Name of your Secondary Dental Insurance Policy Holder s Name Policy Holder s Name Relationship to Patient Relationship to Patient Insured s Birth Date Insured s Birth Date Social Security # Insured s SS# Insurance ID# (If different from SS#) Insurance ID# (If different from SS#) Claim Address Claim Address Insurance Phone # Insurance Phone # Group # Group # DENTAL HISTORY REASON FOR TODAY S VISIT CIGARETTE, PIPE, OR CIGAR SMOKING ORTHODONTIC TREATMENT CLICKING OR POPPING IN JAW PAIN AROUND EAR FORMER DENTIST DRY MOUTH PERIODONTAL TREATMENT CITY/STATE FINGERNAIL BITING SENSITIVITY TO COLD DATE OF LAST DENTAL CARE FOOD COLLECTION BETWEEN TEETH SENSITIVITY TO HEAT DATE OF LAST DENTAL XRAYS FOREIGN OBJECTS SENSITIVITY TO SWEETS PLEASE INDICATE IF YOU HAVE OR HAVE HAD GRINDING TEETH SENSITIVITY WHEN BITING ANY OF THE FOLLOWING: GUMS SWOLLEN OR TENDER SORES OR GROWTHS IN MOUTH BAD BREATH JAW PAIN OR TIREDNESS TOBACCO, SMOKELESS / OTHER BLEEDING GUMS LIP OR CHEEK BITING HOW OFTEN DO YOU BRUSH? BLISTERS ON LIPS OR MOUTH LOOSE TEETH OR BROKEN FILLINGS BURNING SENSATION ON TONGUE MOUTH BREATHING HOW OFTEN DO YOU FLOSS? CHEW ON ONE SIDE OF THE MOUTH MOUTH PAIN WITH BRUSHING Are you dissatisfied with your teeth, &/or their appearance?
2 THE PROVINCES DENTAL CARE Patient Birthdate Sex HEALTH HISTORY Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine) and Redux (dexfenfluramine)? [ ] YES [ ] NO Place a mark to indicate if you have, or have had in the past, any of the following: AIDS/HIV CONGENITAL HEART HIGH BLOOD PRESSURE SHORTNESS OF BREATH ANEMIA LESIONS JAUNDICE SINUS TROUBLE ARTHRITIS, RHEUMATISM CORTISONE TREATMENTS JAW PAIN SKIN RASH ARTIFICIAL HEART VALVE COUGH, PERSISTENT KIDNEY DISEASE SPECIAL DIETARY NEEDS ARTIFICIAL JOINTS DIABETES LIVER DISEASE STROKE ASTHMA EMPHYSEMA LOW BLOOD PRESSURE SWOLLEN FEET OR ANKLES BULIMIA EPILEPSY MITRAL VALVE PROLAPSE SWOLLEN NECK GLANDS BLEEDING ABNORMALLY, FAINTING OR DIZZINESS NERVOUS PROBLEMS THYROID PROBLEMS W/ SURGERY, EXTRACTIONS GLAUCOMA PACEMAKER TONSILLITIS BLOOD DISEASE HEADACHES PSYCHIATRIC CARE TUBERCULOSIS CANCER HEART MURMUR RADIATION TREATMENT TUMOR OR GROWTH ON CHEMICAL DEPENDENCY HEART PROBLEMS RESPIRATORY DISEASE HEAD OR NECK CHEMOTHERAPY HEPATITIS TYPE RHEUMATIC FEVER ULCER CIRCULATORY PROBLEMS HERPES SCARLET FEVER VENEREAL DISEASE Medical Marijuana Usage? [ ] YES [ ] NO Do you wear contact lenses? [ ] YES [ ] NO Women: Are you pregnant? [ ] YES [ ] NO Due Date? Are you nursing? [ ] YES [ ] NO Are you taking birth control? [ ] YES [ ] NO Medications Allergies List any medications you are currently taking, For your health and safety, please mark any and why you take it: Known drug or material allergies: Aspirin Iodine Penicillin Barbituates Latex Sulfa Pharmacy Name Codeine Local Anesthetics Pharmacy Phone Number Other (list): Physician s Name Date of Last Medical Visit Previous hospitalizations, serious illnesses, or operations: I understand that providing incorrect or incomplete information can be very dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status. To the best of my knowledge, I have provided The Provinces Dental Care with accurate and complete health and dental information. I authorize the dental staff to perform the necessary dental services I may need. Patient or Guardian Signature Printed Name Date
3 THE PROVINCES DENTAL CARE FINANCIAL POLICY PLEASE READ & INITIAL EACH PARAGRAPH We appreciate your selection of this office to serve your dental needs. Our interest is to provide our patients with the finest possible, quality dental care. We must attend to the financial aspects of dental treatment as well. Following is an overview of our office financial policy. Payment. Payment in full is required at the time of service. For your convenience, we accept cash, debit, and credit cards, including Visa, Master Card, Discover, and American Express. Our office also offers No Interest and Extended Payment Plans, upon approved credit, through CareCredit. Insurance, if applicable. Dental Insurance never pays for 100% of all dental services. As a courtesy, in most cases, we will bill one dental insurance for your care, providing you give us the needed information for claim submission. At the time of service, we will request from you an initial payment, the estimated portion of the charges which insurance may not cover, including all applicable deductibles and co-pays. Payment from the insurance company is expected within thirty (30) days. If your insurance company has not responded within thirty days from the date of service, the entire balance in full is your immediate responsibility. The account will then be considered aged 30 days. Questions and concerns with your dental coverage and the payment of your claim(s) are the sole responsibility of the insured, and is your responsibility to resolve with the insured s employer and/or dental insurance company. Your coverage is a result of the contract between the insured s employer and the dental insurance company, and our office has no control over payment or non-payment of your claims. As your dental care provider, we advise treatment that is in the best interest of your medical and dental health. Insurance companies select the dental procedures that they will and will not cover without regard to your personal situation, health, and dental needs. It is the sole responsibility of you, the patient, to familiarize yourself with the rules, terms, exclusions, clauses, and benefit limitations of your dental insurance policy. Estimates. Before treatment, we will perform a diagnosis and provide you with an estimate of the charges involved. As treatment progresses, it is possible that additional circumstances not apparent at the initial exam, may be encountered. In this event, we will discuss options with you and proceed upon your approval. Aged Account. All charges are your responsibility, due at time of service. Failure to keep this account current may result in The Provinces Dental Care being unable to provide additional dental services. Default occurs after 30 days, and payment is due in full. I understand that Provinces Dental does not accept payments on balances due for services already received. In the event of a default, I agree that any information collected can be used to collect on my account, and I agree to pay all costs incurred in the attempt to collect on this account, up to and including, but not limited to, late fees, finance charges, collection agency fees, attorney s fees and court costs. Copyright Any comment posted online in any way relating to The Provinces Dental or any Provinces Doctor or Employee, will be the sole right and property of The Provinces Dental, P.C., and the copyright of the content of the comment, rating, or review is hereby assigned to The Provinces Dental, P.C. to utilize or eliminate at our discretion, and/or in order to protect any patient s or employee s anonymity and privacy. Appointments. If unable to keep a scheduled appointment, we ask that you provide us with 48 hours notice as a courtesy. Notice of less than 48 hours will result in a minimum charge of $50.00, the amount to vary depending on the magnitude of the failed appointment. Assignment of Benefit. I agree to be responsible for all charges for dental services and materials. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with my dental claims. I hereby authorize Assignment of Benefit to The Provinces Dental Care. I have read, understand, and agree to the above. Signature of Person Responsible for Account Printed Name of Person Responsible for Account Date
4 THE PROVINCES DENTAL CARE Notice of Privacy Practices Dear Patient, This is not meant to alarm you! Quite the opposite! It is our desire to communicate to you that we take the new federal (HIPAA Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside our office. What has changed? Why a policy now? Very good questions! The most significant variable that has motivated the federal government to implement HIPAA is the rapid evolution of computer technology and its uses in the healthcare community. The government seeks to standardize the protection of your PHI how your Personal Health Information is transmitted. This challenges us to take a good look at how your information is used in our office, not only in our computers, but with the phone, fax, copy machines, and charts. This has been an important exercise for us because it has disciplined us to put into writing a policy and procedure to ensure the protection of your health information. We want you to know about these policies and procedures which we developed to make sure your PHI will not be shared with anyone who does not require it. Our office is subject to state and federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures, and your rights as our valuable patient. Our promise to you: We will use and communicate your PHI only for the purpose of providing your treatment, obtaining payment, and conducting dental care operations. Your PHI will never be used for any other purpose unless we have asked for and gotten your permission. How your Health Information may be used To Provide Treatment We will use your PHI inside our office to provide you with the best dental care possible! This may include office and clerical procedures used to streamline coordination between the Doctor, his Assistants, Hygienists, and business office staff. In addition, your treatment may require us to share your PHI with other entities such as referring Doctors, Clinical Laboratories, or your pharmacy. To Obtain Payment We may include your PHI with paperwork sent to collect payment for the services you receive in our office, such as with insurance forms sent either through the mail or electronically. We will be sure to only work with companies with a similar commitment to the protection of your PHI. To Conduct Dental Care Operations Your PHI may be used during performance reviews or training of our staff. It is possible your PHI would be disclosed during audits by insurance companies or government agencies as a part of their quality assurance or compliance reviews. Your PHI may be reviewed in the process of certification, licensing, or credentialing. In Patient Reminders Because we believe regular care is very important to your dental health, we will remind you of an appointment you ve scheduled or that it is time to contact us and make an appointment. Additionally, we may contact you to follow up on your treatment or to inform you of treatment options that may be available for you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best possible preventative, restorative, and cosmetic treatment modern dentistry can provide. This may include postcards, folding postcards, letters, voic messages, and electronic reminders such as (unless you tell us that you do not want to receive these reminders). Abuse or Neglect We will notify the proper government agency if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclosure only
5 when we are compelled by our ethical judgment, when we are specifically required or authorized by law or with the patient s agreement....public Health or National Security We may be required to disclose PHI to federal officials or military authorities when it is necessary to complete an investigation related to public health or national security. For Law Enforcement We may be required to disclose PHI to a law enforcement official for law enforcement purposes. An example would be if you are a victim of a crime or in order to report a crime. Family, Friends, and Caregivers With your permission, we may share your PHI with those you tell us will be helping you with your home hygiene, treatment, medication, or payment. If there is an emergency, and you are unable to tell us what you want, we will use our very best judgment in sharing your PHI, and only when it will be important to those participating in providing your care. To Coroners, Funeral Directors, and Medical Examiners We may be required by law to provide PHI to coroners, funeral directors, or medical examiners in order to determine a cause of death or prepare for a funeral. Research Advances in dental knowledge often involve learning from the careful study of the dental histories of prior patients. Formal review of dental histories as a part of a research study will happen only under the ethical guidance of an Institutional Review Board. Your Rights as a Patient This new law is careful to describe that you have the following rights related to your PHI: Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. Confidential Communications You have the right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. Inspect and Copy You have the right to inspect and copy your PHI. Amend You have the right to amend your PHI. Disclosures You have the right to receive an accounting of disclosures of PHI. Paper Copy You have the right to obtain a paper copy of this notice from us upon request. Privacy Practices Acknowledgement I have received the Notice of Privacy Practices and I have been provided with an opportunity to review it. Print Patient Name Signature of Patient or Responsible Party Birth Date Today s Date Office Staff Only: Written acknowledgement could not be documented due to [ ] Patient refused to sign [ ] Personal representative not able to sign [ ] Language, communication, or effects of disability impeded acknowledgement [ ] Emergency care impeded acknowledgement [ ] Other, please specify
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.
DENTAL 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
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:
Patient 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
Consent 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
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
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
PATIENT INFORMATION. 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:
Michael Mabry, DDS, MAGD
PATIENT INFORMATION Date: / / PATIENT NAME: Last First Middle Initial Male Female Date of Birth: Married Widowed Single Minor Separated Divorced Partnered ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK PHONE:
Jackson Center Dental
Patient Information Jackson Center Dental Insurance Information Date: Social Security#: Patient Last Name: Patient First Name: Address: City: State: Zip Code: Sex: o Male o Female Birthday Date: Age: Married
DENTAL REGISTRATION AND HEALTH HISTORY
DENTAL REGISTRATION AND HEALTH HISTORY PATIENT INFORMATION Soc. Security #/Patient ID #: Patient Name: Gender: Date of Birth: Age: E-mail: Phone (Home): (Work): Ext: (Cell): Address: City: State: Zip:
LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas
LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS Patient Information Patient Name: Date: Last First Mi Preferred Gender(M/F): Marital Status: Birth Date: Social Security # Driver s License#: E-Mail Address: State
Subscriber's Name. Date of Birth. Secondary Insurance Group # ID # DENTAL HISTORY. Yes Yes Yes Yes Yes Yes Yes Yes Yes
PATIENT INFORMATION Last Name First Name Middle Sex: Marital Status: of Birth SSN Address City State Zip Code E-mail Phone # Cell # Contact preference: Employer/School Occupation Employer/School Address
PATIENT REGISTRATION & HEALTH HISTORY FORM
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:
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
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
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
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 Registration
Patient Registration Date: First Name Last Name Middle Initial Preferred Name E-mail Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers
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
Acknowledgement of Receipt of Notice of Privacy Practices
HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good
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
Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n
Shore Smiles Family & Cosmetic Dentistry 654 Newman Springs Road, Lincroft, New Jersey 07738 Phone: 732-747-4444 Fax: 732-747-4003 Welcome Take a few minutes to answer the following questions so we can
All Dental 76 Otis Street Westborough, MA 01581
All Dental 76 Otis Street Westborough, MA 01581 Date: SSN: Primary Care Physician: Physician Phone: Patient Information Patient Name: Last First Address: City: State: Zip: Birthday: / / Employer: Occupation:
Prince Family Dentistry
Prince Family Dentistry 702-240-0202 830 S. Durango Dr., Ste. 104 Las Vegas, NV 89145 PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married {
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
Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone
Patient Information NameSoc. Sec. # Last Name First Name Middle Initial Address City State _ Zip _ Home Phone _ Cell Phone _ Sex M F Birthdate _ Single Married Widowed Separated Divorced Patient Employed
12. Is there anything we can do to enhance your smile and optimize your oral health? Yes No Tell us more:
Smile and Oral Health Evaluation Thank you in advance for taking the time to allow your new dental team the opportunity to get to know you better. Where applicable please rate your responses from 1-10
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
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,
Primary Insurance Information
Durell Family Den-stry Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you.
New Patient Registration
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.
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
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
3 Home Work Cell Best time to reach you (Specify someone who does not live in your household.) Name Relationship Home Phone Work/Cell Phone
1 2 Date Patient Address City State Zip Sex: M F Age Birthdate Single Married Widowed Separated Divorced Patient SS# Occupation Employer Employer Address Employer Phone Spouse s Name Birthdate SS# Occupation
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
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
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:
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)
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
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred Birth date: S.S.N.# ID/DL#: Month /Day /Year Address: Street Apt. # City State Zip Telephone: Home # Work#
Patient Information. Your Name: Name you wish to be called: Date: Physical Address: Street Name and Number City Zip Code
Patient Information Welcome to Rivery Dental. Thank you for choosing our office for your dental care. Our primary goal is to help you achieve and maintain your maximum oral health with a smile you are
P A T I E N T R E G I S T R A T I O N
900 MAIN STREET, SUITE 104 RICHARD H. CHANIN, D.D.S GREG B. CINSKI, D.M.D. COSMETIC & FAMILY DENTISTRY www.holbrooksmiles.com P A T I E N T R E G I S T R A T I O N Today s Date Name Preferred Address Telephone:
Lasting Impressions Dentistry Sabrina Habib Heppe DDS, PS (206)
Personal Information Last Name First Name Pref. Name MI Mailing Address Apt # City State Zip Home# ( ) Cell# ( ) Sex: M F E-Mail: Confirmation of Apts by Email? Yes No Date of Birth / / SSN#: Marital Status:
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,
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. 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:
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
PATIENT 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
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
GRAND STRAND DENTISTRY B Hwy 544. Conway, SC 29526
GRAND STRAND DENTISTRY 1867 B Hwy 544 Conway, SC 29526 I,, hereby authorize Grand Strand Dentistry to give the following people information concerning my health, treatment, billing and/or insurance information:
538 SAVANNAH HIGHWAY CHARLESTON, SC (843)
DENTAL HISTORY Name: Reason for today s visit: Previous dentist: Previous dentist s phone number: Date of last dental care: Last dental x-rays: Please indicate any of the following issues that apply with
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 Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
Jane Otto Family Dentistry Gravois Road St. Louis, MO (314)
Jane Otto Family Dentistry 11521 Gravois Road St. Louis, MO 63126 (314) 842-2442 PATIENT INFORMATION Patient Name: Last First MI Male Female Married Single Child Other: Social Security #: Date of Birth:
Patient: 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
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 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
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
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
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?
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
PATIENT 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,
DENTAL HISTORY AND CONSENT FOR TREATMENT
DENTAL HISTORY AND CONSENT FOR TREATMENT Reason for seeking dental care at this time of last dental visit Reason? of last X-rays Former dentist City/state How often do you: Brush times per Floss times
My Scottsdale Dentist. Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle):
My Scottsdale Dentist Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle): Single / Married / Other: Spouse/Domestic Partner Name: Tel. No.: Social Security # Driver
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
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
DAHL DENTISTRY. 46 PARK PLACE, SUITE A BRANFORD, CT (203) (203) FAX
MEDICAL HISTORY Please fill out this form as completely as possible. This information is essential for our staff to provide dental care in a manner that is compatible with your general health. Your cooperation
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
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
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
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
Insurance 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
Welcome 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
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:
Dr. 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
-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
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
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
PATIENT REGISTRATION AND HISTORY
PATIENT REGISTRATION AND HISTORY Today s Date: Patient s Name DOB: Sex: Male Female If a Child, Parent s Name: Who does child reside with (name and relationship): Home Address: City: State: Zip: Home Phone
Kathryn 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
Georgia 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:
Patient ad t Information. Insurance Information. Dental History
Patient ad t Information Full Name Preferred Name Birth Date / / Age Today s Date Mailing Address Street Address Home Phone ( ) Cell Phone ( ) Email Check Appropriate Box: Minor Single Married Divorced
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
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
NEW PATIENT REGISTRATION FORM (PLEASE PRINT)
NEW PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT INFORMATION Full Legal Name (First) (Middle) (Last) Preferred Name (Nickname) Address Apt. No. City State Zip E-mail Home Phone: Work Phone Cell Phone:
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
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:
WELCOME 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
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
Patient 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
Firewheel 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:
Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:
David B. Epstein DDS 1 0 0 1 M E D I C A L P L A Z A D R # 3 0 0, T H E W O O D L A N D S, T X 7 7 3 8 0 281-367- 3 0 8 5 d r e p s t e i n @ t h e w o o d l a n d s d e n t a l. c o m Patient Information
Brighter Smiles Family Dentistry
Brighter Smiles Family Dentistry Welcome To Our Office! Our team believes that our patients are the most important people in the world. We appreciate that you have chosen our team as your dental family.
Patient Information. Male Female Married Single Child Other. Health Information
Patient Name Patient Information Last, First MI (Preferred Name) D ate: Social Security #: Birth Date: Driver s Lic #: Cell phone Phone (Home): (Work): Ext: Address: Street Apartment # City State Zip Code
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:
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
LONDON BRIDGE SMILES Patient Information (please print) Name Social Sec. # Date of Birth Male/Female First MI Last Address City State Zip Home Phone Cell Phone E-mail Employer Occupation Work Phone Business
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
Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc. Birth Date: Social Security # Previous Visit Date
Welcome to Dr. Peer s Office New Patient Registration Form Patient Name: Last First MI Preferred Name Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc Birth Date: Social
X X Capistrano Children s Dentistry Patient Information Adult Form
X X Capistrano Children s Dentistry Patient Information Adult Form Name: Birthdate: Age: Home Address: Sex: Male Female Occupation: Cell Phone: ( ) - Social Security #: Home Phone: ( ) - Medical Doctor: