What testing have you had that is relevant to today s visit? (i.e. CT scan, MRI, hearing test)
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- Christine Betty Taylor
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1 BOSTON ENT ASSOCIATES 560 Hillside Ave, Suite H R. William Mason, M.D Faulkner Hospital Needham, MA Joshua Kessler, M.D Centre St., Suite Rebecca Stone, M.D. Jamaica Plain, MA William Innis, M.D Mariah Samara, M.D. *********************************************************************************************************************** Name: Age: of Birth: Primary Care Physician: Today s : PCP Hospital Affiliation: What is your primary reason for today s visit? What testing have you had that is relevant to today s visit? (i.e. CT scan, MRI, hearing test) MEDICAL HISTORY (please circle all that apply): Do you have a history of (please circle): High blood pressure Asthma Heart Disease Diabetes NONE Please list any other medical conditions you may have: Operations of the Head and Neck: MEDICATIONS List current medications (please provide list if available): Please list ALLERGIES to medications or anesthesia: Name and location of your pharmacy: SOCIAL and FAMILY HISTORY Do you currently smoke? Have you smoked in the past? Do you currently drink alcohol? If no, did you drink alcohol in the past? History of loud noise exposure? Describe: If so, how much? If so, how much? How much? How much? Do you have a family history of hearing loss under age 65, cancer of the head and neck, or bleeding disorders, or reactions to general anesthesia? Or NONE Please list your height and weight: lbs. ft. inches Have you ever had general anesthesia? Yes No
2 Todays : Boston ENT Associates Patient Registration Form Name / Address Last Name: First Name: MI: Home Address1: Home Phone ( ) - Address2: City: State: Zip - Statistics Soc. Sec. #: - - of Birth: Cell Phone ( ) - Sex: Male / Female Employer: Work Ph. ( ) - Marital Status (circle one) Married, Single, Divorced, Widow, Oth. Spouse / Next of Kin: Next of Kin Phone: ( ) - Responsible Party: Referring Physician Primary Care Doctor: Referring MD: Insurance Information Primary Insurance Company Identification or Certificate # Group Number Name of insured if not self: Insured of Birth: Insured Employer: Relation to Insured Self, Spouse, Child Insured Soc. Sec. Employment Status: Full Time Part-time Student Other Second Insurance Company Identification or Certificate # Group Number Name of insured if not self: Insured of Birth: Insured Employer: Relation to Insured Self, Spouse, Child Insured Soc. Sec. Other Insurance Is this Workers Comp.? Y / N Motor Vehicle Accident? Y / N Is this Personal Injury? Y / N Authorization and Financial Policy: I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS FOR MEDICAL BENEFITS. I AUTHORIZE PAYMENT OF ALL MEDICAL BENEFITS TO BOSTON ENT ASSOCIATES FOR SERVICES PROVIDED. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AND ALL BALANCES NOT PAID BY MY INSURANCE COMPANY. Your Signature:
3 BOSTON ENT ASSOCIATES 560 Hillside Ave, Suite H R. William Mason, M.D Faulkner Hospital Needham, MA Joshua Kessler, M.D Centre St., Suite Rebecca Stone, M.D. Jamaica Plain, MA William Innis, M.D Mariah Samara, M.D. Have you ever had trouble with (Please Circle Specific Problem) 1 Your breathing or lungs, asthma, bronchitis, emphysema, pneumonia, tuberculosis, abnormal chest x-ray, recent colds or wheezing or coughing? 2 Your heart, heart attacks, chest pain or angina, shortness of breath, pressure in your chest, palpitations or irregular heartbeat, abnormal electrocardiogram? 3 Not being able to walk up two flights of stairs without stopping to catch your breath? 4 Rheumatic fever or mitral valve prolapse or been told that you have a heart murmur or click? 5 Have you been told to regularly take antibiotics before dental care? 6 Ulcers, gastritis, a hiatus hernia, frequent heartburn, yellow jaundice, hepatitis? 7 Epilepsy, seizures, strokes, dizzy or fainting spells, weakness in arms or legs, muscle disease? 8 Your blood pressure or are you taking medicines for your blood pressure? 9 Your kidneys, or do you take diuretics or water pills? 10 Bleeding, blood clots, frequent nose bleeds, anemia, or do you have sickle cell anemia? 11 Thyroid disease or been told you have diabetes or high blood sugar? 12 Cancer, or received chemotherapy or radiation therapy? Yes No Have you ever 1 Had allergies to drugs or dyes? What type of reaction? Rash Hives Nausea Swelling Trouble breathing 2 Smoked cigarettes? If yes, how many packs per day week How many years? Do you smoke now? 1 Do you drink alcohol? How many glasses each day? Week Month 2 What medicines have you been taking during the past month? (Please include aspirin, AlkaSelzer, Birth Control pills, etc.) 3 What herbal supplements have you been taking during the past month? (i.e. St. John s Wort, Ginko Biloba, etc.) 4 Have you taken steroids (Prednisone or Cortisone) during the past six months? 5 Are you pregnant? Patient Signature
4 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HIPAA PRIVACY PRACTICES (a copy of our privacy notice is available in the waiting room, or we can provide you with your own copy upon request) I have been given a copy of Boston ENT Associates, P.C. s Notice of Privacy Practices ( Notice ), which describes how my health information is used and shared. I understand that Boston ENT Associates, P.C. has the right to change this Notice at any time. I may obtain a current copy by requesting one at a Boston ENT location, or by visiting the Boston ENT website at My signature below acknowledges that a copy of the Notice of Privacy Practices has been made available to me: Signature of Patient or Representative Print Name Title of Personal Representative (e.g. Guardian, Executor of Estate, Health Care Proxy) FOR FACILITY USE ONLY: COMPLETE THIS SECTION IF YOU ARE UNABLE TO OBTAIN A SIGNATURE. 1. If the patient or personal representative is unable or unwilling to sign this Acknowledgement, or the Acknowledgement is not signed for any other reason, state the reason: 2. Describe the steps taken to obtain the patient s (or personal representative s) signature on the Acknowledgement: Completed by: Signature of Boston ENT Representative Print Name
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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:
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 INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
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PATIENT REGISTRATION
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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
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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
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.
PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
WELCOME TO LEHIGH DENTAL
WELCOME TO LEHIGH DENTAL The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate,
WELCOME PATIENT INFORMATION 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
PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION
PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION DATE Please Print All Information LAST NAME FIRST NAME MI ADDRESS CITY ST ZIP PHONE EMPLOYER WORK PHONE DATE OF BIRTH AGE SEX SOC. SEC.
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No:
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
WELCOME 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
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
JOHN R. SIMPSON, D.D.S, M.D., F.A.C.S.
JOHN R. SIMPSON, D.D.S, M.D., F.A.C.S. EAR, NOSE AND THROAT HEAD AND NECK SURGERY ENDOSCOPIC SINUS SURGERY (3D Guided) Balloon Sinuplasty, Surgery for Sleep Apnea NORTHEAST GEORGIA EAR, NOSE, THROAT HEAD
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State:
Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext. Date of Birth: Sex: M F Social Security Number:
PATIENT INFORMATION Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext Date of Birth: Sex: M F Social Security Number: Patient E-mail Address: Marital Status: