Patient Registration
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- Bruce Barton
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1 Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number: I would prefer NOT to receive correspondences via text message I would prefer NOT to receive correspondences via How did you hear about our office? Primary Insurance Information Secondary Insurance Information Subscriber Name: Subscriber DOB: Subscriber Address (if different): Subscriber Name: Subscriber DOB: Subscriber Address (if different): Employer: Insurance Company: Insurance Phone: Member ID#: Plan Group#: Employer: Insurance Company: Insurance Phone: Member ID#: Plan Group#:
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3 Dental History Reason for visit Former Dentist/Location Date of last dental visit Date of last dental x-rays Check to indicate if you have any of the following: Bad Breath Lip or Cheek Biting Bleeding Gums Loose Teeth Broken Fillings Mouth Breathing Clicking/Popping Jaw Mouth Pain Dry Mouth Orthodontic Treatment Fingernail Biting Pain Around Ear Food Collection in Teeth Periodontal Treatment Foreign Objects Sores in Mouth Grinding teeth Sensitivity to Cold Gums Swollen/Tender Sensitivity to Heat Jaw Pain or Tiredness Other How often do you brush your teeth? How often do you floss your teeth? If you can change anything about your smile, what would you change?
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5 Appointment Cancellation Policy We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled that time has been set aside for you, and when it is missed that time cannot be used to treat another patient. Our policy is as follows: We require that you give our office 48 hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $50.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred without the payment of this fee. Additionally, if you are more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $50.00 cancellation fee will be applied. If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have. We thank you for your patronage I have read and understand the Appointment Cancellation Policy of the practive and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice Patient Signature Date
6 Financial Policy Our office is committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees or your financial responsibility. Patients must complete all information forms prior to seeing the dentist. A copy of your insurance card(s) will be retained for your file. If your insurance changes, it is your responsibility to notify our dental office of that change. Payments Co-Payments: By law, we must collect your carrier-designated co-payment at the time of service. Please be prepared to pay that co-payment at each visit. Non Co-Payment Plans: If your plan does not require a co-payment and we participate in your plan, we will accept the designated fee. You are responsible for any deductible and balance your plan indicates on their explanation of benefits. Self-Pay: Payment is expected at the time of service. Account Balances: You are responsible for timely payment of your account. Our offices reserve the right to reschedule or deny a future appointment on any delinquent accounts. Return Check Policy and Fee We accept local and out of state checks. Any check that is not cleared through the bank and is returned to our office because of an insufficient balance will be returned to the patient and the patient will be charged $ Providing Insurance Information Insurance coverage is a contract between you and your carrier. It is your responsibility to provide Seaport Dental with valid insurance information prior to your appointment. In the event that you can not provide the information, or the coverage is not active, Seaport Dental will ask you to pay in full for all services at the time of your visit. If valid information is provided within 30 days of your visit, Seaport Dental will bill the new insurance and once payment is received your account will be refunded. Refunds can be used towards future work or made to the original form of payment. Seaport Dental does not keep any credit card numbers so you will need to contact the office to provide that information. If updated insurance information is received after 30 days from the date of your visit Seaport Dental will provide you with the information to submit the claim for reimbursement. Your insurance company will pay you directly. No refunds will be made by Seaport Dental and we will be unable to honor any insurance negotiated fees on contract adjustments.
7 Dental Insurance As a courtesy to our patients, we will file your dental claims and accept assignment of benefits from participating insurance providers. In order for us to be able to provide this service, please provide us with accurate dental information. There are many different types of insurance policies available. Your employer has arranged this contract between you, your employer and the insurance company. We are not a party to this contract. Ultimately, any balance remaining for services is your responsibility. Out staff will assist you in obtaining your maximum benefits under the guidelines of your policy. Usual and Customary is a term developed by the insurance carrier industry to reflect average charges from specific dentists in designated geographic localities. The usual and customary amount noted on the explanation on benefits does not accurately reflect individual charges. Therefore, the usual and customary charges DO NOT override our fees. THANK YOU for taking the time to review our policy. Please feel free to ask any questions or share specific concerns. Patient Signature Date If patient is a minor, please state your relationship WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, AMEX, DISCOVER, CARE CREDIT
8 General Informed Consent 1. I hereby consent to and authorize the performance of dental procedures integral to my general dental care upon myself for the following purpose(s): Preventive procedures including but not limited to; prophylaxis cleanings, examinations, restorations, periodontal treatments, endodontic treatments and diagnostic radiographs. Seaport Dental complies with the ADA recommendation for radiographs. This includes a minimum of yearly bitewings and a full mouth series once every 5 years. 2. I am aware that during the course of treatment changes in my treatment plan may become necessary. I further understand and necessary changes will be explained to me, and the opportunity will be given to ask questions. 3. I understand that the x-rays, charts and any other results from this treatment will be used for educational purposes when working with dental students. 4. The nature and purposes of the treatments listed above, and any possible risk involved, will be explained fully to me in advance of treatment. 5. This consent will be in effect for the duration of my tenure as a patient of Seaport Dental. 6. I understand that Seaport Dental will assist me in obtaining maximum benefits under the Guidelines of my policy and agree that all costs or balances not covered by my insurance will be my full responsibility. Patient Signature Date
9 Seaport Dental Associates ACKNOWLEDGEMENT OF RECEIPT OF HIPPA NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a copy of this Dental Practice s HIPPA Notice of Privacy Practices. (Patient Name) (Patient Signature (Date) OR (Signature of Personal Representative) Authority of Personal Representative to Sign for Patient (check one): Parent Guardian Power of Attorney Other Please Note: It is your right to refuse to sign this Acknowledgement. I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: ---- An emergency prevented us from obtaining acknowledgment A communication barrier prevented us from obtaining acknowledgement The individual was unwilling to sign Other: Staff Member signature Date
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
Anthem Hills Dental PATIENT INFORMATION
PATIENT INFORMATION Patient Name DOB Date Address City ST Zip Preferred Contact # Home # Cell # E-mail _ SSN Marital Status: S M Other Employer Type of Work Work # Business Address_ City ST Zip Emergency
Patient Information & Demographics
ARTISTRY INTEGRITY PASSION 101 NORTH MARY STREET HEDGESVILLE, WV. 25427 NEW UPDATE Patient Information & Demographics Appointment : Appointment Time: am pm Name: Nickname: Address: of birth: SS# Marital
Patient Dental History
Justin M. Russo, DDS, PLLC What is the main reason for your visit today? Other/Comments: Patient Dental History Cleaning Tooth Pain Sensitivity Whitening Fresher Breath Implants Dentures When was your
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:
York Smile Care. First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer:
Patient Information Circle One: Dr/Mr/Mrs/MS/Miss First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer: Email Address: May we contact you by Email(circle)
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 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
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
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
Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :
Patient Information: Fairview Dental Date: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: : Email: Check one : Child Single Married Divorced Widowed
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)
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
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.
Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:
First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
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
NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK
PATIENT INFORMATION NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - ADDRESS CITY STATE ZIP HOME PHONE CELL OTHER EMAIL How did you hear about our office? HEAD OF HOUSEHOLD NAME: LAST FIRST MI
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Date / / Welcome Patient s Name Last First M.I. Address City State Zip Code Home Phone
PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY:
(PLEASE PRINT CLEARLY) Date: PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY: HOME PHONE: CELL PHONE: WORK PHONE: WHAT PHONE NUMBER IS BEST TO GET A HOLD
Dental Insurance Information
Dr. Talib Ali DMD Dr. Ali Mualla DDS Patient s Name Social Security # Gender Birthdate Email Address Home Address City State Zip Home Phone Cell Phone Most Recent Dental Visit Who may we thank for your
CONSENT TO PROCEED. Patient Name: (Patient, legal guardian or authorized agent of patient)
CONSENT TO PROCEED I authorize Dr. Tyson Pickett and/or such associates or assistants as s/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health
PATIENT REGISTRATION
PATIENT REGISTRATION DEERBROOK FAMILY Dentistry 20440 Hwy 59 N, Suite 300, Humble, TX 77338 281-548-0008 Fax: 281-548-0238 Info@Deerbrookfamilydentistry.com General Consent I,, consent to be a patient
All About Kids Pediatric Dentistry
Dr. Courtney Wilson & Dr. Melanie Nesbitt Patient Registration Date: Patient s Name Nickname Birth date Age Sex Patient s Address Contact Phone # street city state zip Father s Name DOB Mother s Name DOB
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
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 {
Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:
Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information
NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. Insurance Co. Name Name
Health History Form Dr. Lisa LaPresti Today s Date: NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. 1. Tell Us About Your Child 5. Child s Name
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:
Date How did you hear about Shine? P A T I E NT I N F O R M A T I O N
How did you hear about Shine? P A T I E NT I N F O R M A T I O N 1. Patient's Name of Birth / / Gender: Male Female 2. Patient's Name of Birth / / Gender: Male Female 3. Patient's Name of Birth / / Gender:
WELCOME TO RED BANK SMILES! PLEASE, TAKE A MOMENT TO PROVIDE US WITH THE FOLLOWING INFORMATION
! WELCOME TO RED BANK SMILES! PLEASE, TAKE A MOMENT TO PROVIDE US WITH THE FOLLOWING INFORMATION I. PATIENT INFORMATION NAME: Name you prefer to be called by, or pronunciation: BIRTHDATE: / / SEX: M /
Name: Preferred Name: Social Security Number: Referred By: Gender: Marital Status: Date of Birth: Street Address (No P.O. Box): City: State: Zip Code:
Name: Preferred Name: Social Security Number: Referred By: _ Gender: Marital Status: Date of Birth: Street Address (No P.O. Box): City: State: Zip Code: Cell Phone: Home Phone: Email: Your Employer: Work
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,
Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:
David B. Epstein DDS 1 0 0 1 M E D I C A L P L A Z A D R # 3 0 0, T H E W O O D L A N D S, T X 7 7 3 8 0 281-367- 3 0 8 5 d r e p s t e i n @ t h e w o o d l a n d s d e n t a l. c o m Patient Information
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Welcome Date / / Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Patient s Name Last First M.I. Address City State Zip Code Home Phone
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
2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)
2460 India Hook Road, Suite 106 Rock Hill, SC 29732 E-mail: drj@rockhillkids.com Tel: (803) 327-3327 Fax: (803) 334-3474 Welcome to our practice! Please carefully complete this form so that we may better
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
Acquaintance Form & Health History
Acquaintance Form & Health History Date Patient s Name Marital Status Nickname, if preferred Spouse s Name (if married) Date of Birth Residence Street address City Zip Home Phone Cell # Employer Position
Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
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
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
INSURANCE INFORMATION
To provide the safest and most comprehensive dental care for your child, we ask for your cooperation in completing our detailed questionnaire. Date: Child s name: Nickname: Birthdate: Gender: M F Home
Dental. North Naples. Laura Van Varick, D.D.S. Notice Of Privacv Practices
North Naples Dental Laura Van Varick, D.D.S. Notice Of Privacv Practices This Notice Describes How Health Information About You May Be Used And Disclosed And How You Can Get Access To This Information.
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. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed E-mail address:
HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance
HEALTH HISTORY FORM 4 How Did You Hear About Us? 5 Who is Accompanying the Child Today? Name Today s 1 2 3 Tell Us About Your Child Patient s Full Name Preferred Name Male Female Siblings We Treat Patient
Talia Pike DMD Patient Information
Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Email Address Parent Name
FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.
FINANCIAL AGREEMENT- PAYMENT IS REQUIRED FOR ALL DENTAL SERVICES AT THE TIME TREATMENT IS RENDERED. We accept Visa, MasterCard, Discover, American Express, Care Credit, Cash or Check. INSURANCE FILING-
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
Name Preferred Name Sex. Home Address. Home Phone Age Date of Birth. School Grade. How did you hear about us?
ID CHECKED (RESPONSIBLE PARTY) INFORMATION (CHILD UNDER 18) Name Preferred Name Sex Home Address Home Phone Age School Grade How did you hear about us? What is the name/phone number of the child s previous
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:
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:
NEW PATIENT REGISTRATION FORM (PLEASE PRINT)
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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
H&M Family Dentistry New Patient Information page
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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
❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
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.
Please check if patient is a minor/child. First Name: Last Name: Middle Initial: Preferred name: Address: City: State: Zip: Home: Work: Cell:
Guest Form Jon M Van Slate, DDS,FAGD,LVIF 1011 Augusta Dr, Suite 201 Houston, Texas 77057 (713) 783-1993 info@drvanslate.com www.drvanslate.com Patient Information Please check if patient is a minor/child
Just for Kids Pediatric Dentistry, Ltd. Patient Information
Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:
Patient Information. Responsible Party. Notify in case of emergency?
We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward
DENTAL HISTORY. When was your last dental visit? Please describe the main reason for your consultation/new patient appointment:
DENTAL HISTORY When was your last dental visit? Please describe the main reason for your consultation/new patient appointment: DO YOU HAVE ANY OF THE FOLLOWING: Discolored or dark teeth? _ Yes _ No Chipped,
DENTAL HISTORY AND CONSENT FOR TREATMENT
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Dr. Víctor Vergara DMD P.A Livingston Rd, Bldg # 100, Ste. #106, Naples, FL Fax PATIENT HEALTH RECORD
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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
Dr. Paul Jang Dentistry Health Questionnaire
Dr. Paul Jang Dentistry Health Questionnaire General Information How did you hear about us? Mailer Yelp Referral: Other: Primary purpose of visit: Changing Dentists Cleaning Long overdue for dental visit
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
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:
WELCOME TO OUR PRACTICE
WELCOME TO OUR PRACTICE We will like to know your dental concerns and expectations so we can provide you with the best dental care. What are your dental concerns? What would you like to improve, if anything,
Driver s License # Cell Phone Gender Male Female. Single Married Divorced Other. Driver s License # Cell Phone Gender Male Female
Patient Information: Patient Name Home Address City, State, Zip Home Phone Social Security # Birthdate Driver s License # Cell Phone Email Gender Male Female Work Phone Insurance Information: Marital Status
PATIENT INFORMATION 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
DeMercy Dental Crabapple Road, Ste. 140 Roswell, GA
PATIENT REGISTRATION (Please print) Patient s Legal Name: Last First Middle Preferred Name: Street Address: City St Zip Phone Numbers: Home Cell Work Email address: Which method is best to confirm appointments
Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
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Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred
Personal Information. Date of Birth: / / SSN: - - Single Married Child Other. Home Address: Street City State Zip
Dr. Harvey Levy & Associates, P.C. 198 Thomas Johnson Drive, Suite 108, Frederick, MD 21702 Office: (301) 663-8300 Fax: (301) 682-3993 E-mail: appointments@drhlevyassoc.com Personal Information Patient
Patient 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 INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date
PATIENT INFORMATION Name Soc. Sec. # - - Last Name First Name Initial Address City State Zip code E mail address Sex M F Age Birth date Home phone Mobile phone Work phone In case of emergency who should
*Are you allergic to: Penicillin Codeine Local Anesthetics Latex Other
PATIENT HEALTH RECORD Date Dr. Mr. Mrs. Ms. E-mail Address City State Zip Home Phone Work Phone Cell Phone Birthdate Sex Marital Status Occupation SSN Emergency, Contact Name, and Number Whom/what may
Ottesen Family Dentistry * Dr. Pamela Ottesen, DMD * *
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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:
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:
Today s Date / / Male Female. Child s Name Preferred Name. Child s Address City Zip. How were you referred to our office?
Today s Date / / Male Female Child s Name Preferred Name Child s Birthday / / Cell # ( ) - Home # ( ) - Child s Address City Zip How were you referred to our office? Who is accompanying this child today?
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
NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service.
6101 Redwood Square Center Suite 300 Centreville, VA 20121 5047 Backlick Road Suite A & B Annandale, VA 22003 Health History Form Today s Date: NOTE: The parent or Guardian who accompanies the child is
Welcome to Tyler L. Smith Family Dentistry
Today s : Patient Information Welcome to Tyler L. Smith Family Dentistry Last: First: Middle Initial: _ Preferred: Address: City: State: Zip: Home #: Email: Cell #: Work #: Sex: Birth : Social Security
Patient Information. Health Information
Henritze Dental Group 4119 Brandon Ave. SW ROANOKE VA, 24018 (540) 776-6555 Email: brandon@henritzedental.com Website: www.henritzedental.com Steven N. Anama, DDS Patient Information Patient Name: Date:
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
Patient Information. Your Name: Name you wish to be called: Date: Physical Address: Street Name and Number City Zip Code
Patient Information Welcome to Rivery Dental. Thank you for choosing our office for your dental care. Our primary goal is to help you achieve and maintain your maximum oral health with a smile you are
Patient Information. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
PATIENT 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:
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
Authorization to Release Health Information
Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity)
Orthodontics WELCOME TO OUR OFFICE
Orthodontics Ralph S. Kurti, D.D.S., MS., P.A. WELCOME TO OUR OFFICE We are pleased to welcome you as a new patient to our office. We hope that this information will enable you to become more familiar
*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*
DR. MILES MAZZAWI DR. ANTHEA DREW MAZZAWI DR. NIRALI PROCTER 205 Waleska Rd. Suite 2-B Canton, GA 30114 (770) 479-1717 Today s Date: / / We are so pleased to welcome you and your child to our practice!
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
Patient Safety and Privacy. Appointment Policy
Patient Safety and Privacy For your comfort one adult is welcome, but not required to accompany your child to the treatment areas. We do encourage self independence to help promote the growth and development
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
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You may refuse to sign this acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature: : Release of
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
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
Lowrance Dental REGISTRATION FORM (Please Print)
Today s Date: Patient s last name: First: Middle: Lowrance Dental REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Is this your legal name?