Glacier Dental 2421 E Tudor Road Suite #101 Anchorage, AK 99507
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1 Patient Name: LAST FIRST MIDDLE INITIAL Gender: ( )MALE ( )FEMALE Marital Status:( )Married ( ) Single ( ) Child ( ) Other: Social Security #: - - Date of Birth: / / Address: City, State: Zip Code: Phone (Cell #1): (Cell #2): Employer: Work#: Emergency Contact#/Relation: Patient has Medicaid/Denali Kid Care: YES NO STICKER: Medical History *Reason for Visit/Area of Concern: *Date of Last Dental Visit: Have you even been prescribed a BLOOD THINNER or BONE DENSITY Medication?(Fosamax/Plavix/Coumadin/Aspirin) *Are you ALLERGIC: Aspirin/Penicillin/Codeine/Latex/Local Anesthetic/Other: *Have you ever had any complications following dental treatment? YES, explain: *Have you been admitted to the hospital or needed emergency care in the past two years? Explain: *Are you under the care of a physician now? YES, explain: Name of Physician: Office Name: Phone #: *Do you have any HEART PROBLEMS: YES, explain: **Have you ever been told you needed PRE-MEDICATION (antibiotic): FEMALES-Are you or could be PREGNANT at this time? YES, DUE DATE: Trimester: 1 st 2 nd 3 rd Please check ALL that apply: ( ) AIDS ( ) Excessive Bleeding ( ) Liver Disease ( ) Tobacco Use ( ) Allergies: ( ) Fainting ( ) Mental Disorders ( ) Tuberculosis ( ) Glaucoma ( ) Nervous Disorders ( ) Tumors ( ) Anemia ( ) Growths ( ) Pacemaker ( ) Ulcers ( ) Asthma ( ) Heart Murmur ( ) Radiation Treatment ( ) OTHER: ( ) Blood Disease ( ) Hay Fever ( ) Respiratory Problems ( ) Cancer ( ) High or Low Blood Pressure ( ) Rheumatism ( ) Diabetes Type I or II ( ) Hepatitis A/ B/ C ( ) Sinus Problems ( ) Dizziness ( ) Jaundice ( ) Stomach Problems ( )***NONE*** ( ) Epilepsy ( ) Kidney Disease ( ) Stroke Are you currently taking any medications? ( )***NONE*** If YES, please list: To the best of my Knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health, I will inform the doctors at the next appointment without fail. Signature of Patient (If patient is a minor, Parent or Guardian) Date
2 Financial Policy of Glacier Dental/Dr. Jeon s Implant Dentistry We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policies. Payment is due at the time of service, including any deductibles or co-payments. We accept the following forms of payment: 1. Cash 2. Credit Card- Master Card/ Visa/American Express/ Discover 3. Care Credit- offers a separate line of credit to cover your entire family s health care needs. (Please ask the office staff for more information) Insurance Billing You are expected to alert us of all of your dental insurance plans. If you are covered under more than one plan we expect that you disclose to us all of your insurance information. We will contact your insurance for you to inquire about your eligibility and benefits as a professional courtesy. We will inform you of the co-pay and any other costs that are associated with your appointment before we begin your treatment. If there are any changes in your treatment that are determined after we have started we will make you aware of these changes before we continue. We will work to the best of our ability to accommodate your needs and provide you with the options allowed by your insurance with the following stipulations: You are expected to pay in full your co-pay upfront. We will calculate your total for you and present you with cost breakdowns. You will be made aware of any additional payment required for treatment beforehand We will do our best to get accurate information regarding your eligibility and benefits, however, the insurance companies do not always provide us with the most updated information resulting in inaccuracies. In this case we will require you to pay the remaining balance. We do offer Care Credit as a payment plan option. We will allow a 90 day period in which you can pay the remaining balance. If you do not pay in the allotted time your account will be considered overdue.
3 Overdue Accounts Accounts with a balance over 30 days will be turned over to Cornerstone Collection Agency. We have a payment plan option through Care Credit if you wish to make use of this. Once an account has been referred for collection, the doctor-patient relationship is considered terminated. Your records will be referred to a dentist of your choice. Adult Medicaid Only (over 21 years): You have a total of $1150 in dental benefits to use toward dental work each Medicaid fiscal year (July 1 st June 30 th ). Although we check the amount you have available for use, it is your responsibility to disclose any other dental visits you have had during the last year so that we can more accurately calculate how much money you have left. In the event that you do not disclose any dental visits within the last fiscal year and the Medicaid office gives us an inaccurate amount that you have available to use, you are responsible for any difference in cost for services received. Please help us serve you better by letting us know your dental history. I have read and agree to the terms above. I will disclose to Glacier Dental any recent dental visits or appointments made at other dental offices (within the last year) so that they can ensure I do not have to make any additional payments. Signature Date
4 NOTICE OF PRIVACY PRACTICES (Please read carefully and take this with you) Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) we are required to inform you of our privacy policy. We use personal and health information you provide us to assess your condition and provide treatment within our office. Only the doctor and employees have access to your personal and health information. Your information will not be released to outside parties without your consent. Your information will not be provided to outside parties for non-medically related purposes. We may provide your information to Insurance Plans, 3 rd Party Billing Services, or Direct Reimbursement Plans for payment. We may provide your information to collection services. We may provide your information to pharmacies for drug prescription services. We may provide your information to health care providers for consultation purposes, or referrals. You have a right to a written copy of our privacy policy. You have a right to see, amend, and get copies of your records. You have a right to complain about privacy violations. Your consent must be obtained before the information in your records can be disclosed for treatment, payment, or any health care operations. If you want more information about our privacy practices, have questions or concerns, or if you are concerned that we may have violated your privacy rights, please contact: Contact Officer for this Dental Office at By signing the Acknowledgement of receipt form, you have given us permission to release your personal and health information for health care and dental consultations and referrals, billing, collections, and drug prescriptions. If you refuse to sign the Acknowledge of Receipt form, we will not be able to utilize your dental insurance as a means of payment.
5 PRIVACY PRACTICES ACKNOWLEDGEMENT You May Refuse to Sign This Acknowledgement I, have received the Notice of Privacy Practices, and I have been provided an opportunity to review it. Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy practices, but acknowledgement could not be obtained because: ( ) Individual refused to sign ( ) Communications barriers prohibited obtaining the acknowledgement ( ) An emergency situation prevented us from obtaining acknowledgement ( ) Other (Please Specify)
bty DENTAL Group LLC. T: (907)
Patient Name: LAST FIRST MIDDLE INITIAL Gender: ( )MALE ( )FEMALE Marital Status:( )Married ( ) Single ( ) Child ( ) Other: Social Security #: - - of Birth: / / Address: City, State: Zip Code: Phone (Cell
LF Dental T: (949)
Patient Name: LAST FIRST MIDDLE INITIAL Gender: ( )MALE ( )FEMALE Marital Status:( )Married ( ) Single ( ) Child ( ) Other: Social Security #: - - : / / Address: City, State: Zip Code: Phone (Cell #1):
Madison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
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
dental health associates, L.L.P.
JEFFREY G. BELL, D.D.S. GREGORY M. SWENSON, D.D.S. KIHO MA, D.D.S. MATTHEW OLMES, D.M.D susquehanna valley dental health associates, L.L.P. FINANCIAL AGREEMENT "Creating smiles is our business." Thank
Advanced Periodontics & Implant Dentistry of Westchester
Advanced Periodontics & Implant Dentistry of Westchester Patient Name: Social Security #: David L. Sandak, DDS, PC Fara Vossughi, DDS, MS 10 Old Mamaroneck Road, White Plains, NY 10605 Phone: 914-997-1111
Patient Information. City State Zip Code. Date of Last Dental Visit: Reason for this visit: Health Information
Chart #: Patient Information Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Birth Date: Family Status: Date: Phone (Home): (Work): Ext: (Cell) Email: Street Apartment # City State
Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient
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 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
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
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
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
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
Responsible Party Information
3521 COMMERCE CT APPLETON, WI 54911 (920)-734-7730 WELCOME TO OUR PRACTICE Patient Name Preferred Name (Last Name) (First Name) (MI) Gender: Male / Female Family Status: Minor / Single / Married / Other
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring
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 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
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#
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
Cosmetic Dental Concerns
Cosmetic Dental Concerns With recent advancements in materials and techniques, many of our patients are inquiring about cosmetic dental procedures. In order to better serve you, please take a moment to
Patient Information. Health Information
PLEASE COMPLETE PRIOR TO YOUR APPOINTMENT. Return Via: Email:crosspatientcoordinator@verizon.net Fax: 301-662-4945 OR Bring to your appointment Patient Information Patient Name: Date: Last First MI Preferred
YOUR CHILD'S PERSONAL INFORMATION. RESPONSIBLE PARTY (Person responsible for Child's Account)
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.
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.
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 {
Name: Last First Middle. Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Street City State Zip
PATIENT INFORMATION Name: E-mail: Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / Social Security Number: - - Driver s License #: RESPONSIBLE PARTY INFORMATION
JEFFREY L. DONLEVY, D.D.S., M.D. ABRAHAM ESTESS, D.D.S. SAPNA LOHIYA, D.D.S.
Pharmacy Form Please list the name, phone number, and address of the pharmacy that you would like us to submit your electronic prescription to. Patient Name: Pharmacy Name: Pharmacy Adress and Phone#:
New Patient Packet. Patient Name: Today s Date: Last First MI. Preferred Name: Gender: Birth Date: Apartment Number
Patient Information New Patient Packet Patient Name: Today s Date: Last First MI Preferred Name: Gender: Primary Number: (C/W/H) Secondary Number: (C/W/H) Address: Best Email Address to Confirm Appointments:
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
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
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
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
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
Welcome to Marc Berger Choice Dentistry!
Welcome to Marc Berger Choice Dentistry! We are so happy that you are here! We strive to deliver excellent dental services in a caring and relaxing atmosphere. Your addition to our family of happy and
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 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
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 Information Patient Name:, Patient Last Name Patient First Name MI Preferred Male Female Family Status: Married Single Child
Patient Information Patient Name:, Patient Last Name Patient First Name MI Preferred Male Female Family Status: Married Single Child Birthdate Social Security Number e-mail address Home address City State
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
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 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
Fort 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:
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Cell Phone Home
PATIENT REGISTRATION
Dr. Jaish J. Markos State License #053850 50 Dayton Lane Ste #103 Peekskill, NY 10566 Phone: (914) 402 6980 www.gckidsdmd.com PATIENT REGISTRATION Date 1. Tell Us About Your Child Child s First Name Middle
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:
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
Whom do we thank for referring you?
Patient Information Chart #: FOR OFFICE USE ONLY Patient Name: Date: Last, First MI (Preferred Name) Gender: Family Status: E-mail: Social Security #: Birth Date: Phone (Home): (Work): (Cell): Street Apartment
CHILD S REGISTRATION & HISTORY
SIMON P. MORRIS, D.D.S. MAI DINH D.D.S., M.S. CHILD S REGISTRATION & HISTORY Child s name FIRST MIDDLE LAST Nickname Date of birth Age Male Female Child s interests Pets Other children in family who are
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
4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone
Dr. Jeffrey D. Singer Specialty Permit # 5722 1001 Laurel Oak Road Suite C-2 Voorhees, NJ 08043 Phone: (856) 783 3515 Fax: (856) 783 3517 www.abcchildrensdentist.com PATIENT REGISTRATION 1. Tell Us About
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
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,
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
DENTISTRY RALEIGH PATIENT INFORMATION INSURANCE INFORMATION IMPLANT & FAMILY. Primary Insurance: (PLEASE PRESENT INSURANCE CARD TO RECEPTIONIST)
, RTH CAROLINA 27609 WWW.IMPLANTANDFAMILY.COM PATIENT INFORMATION Preferred Date of Birth: Male Female Married Single Address: Street Phone: Home: City Work: Zip Code Cell: SPOUSE INFORMATION Place of
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)
NEW PATIENT REGISTRATION
NEW PATIENT REGISTRATION Patient: Preferred Name: Last Name First Name Middle Initial Home #: Work #: Cell #: Email Address: The best way to contact me is through: Text Email Cell Home Work No preference
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
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
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:
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 Pediatric Dentistry of Greenville!
Welcome to Pediatric Dentistry of Greenville! Child's Information Child's Name(Last, First, Middle Initial) Child's DOB: / / Child's Age Nickname: ( ) Male ( ) Female School : Grade: Child's Home Phone
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
PATIENT 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:
Dental 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
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:
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 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
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
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
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
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:
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:
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
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
Patient Information. Patient Name: ( ) Last Name, First Middle Preferred Name
THOMAS H. WILLIAMS, D.M.D., P.C. Restorative, Cosmetic, & Implant Dentistry Phone (334) 277-9570 Fax (334) 277-0152 Email: office@ thwilliams.com Website: www.thwilliams.com New Patients: Please return
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 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
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
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 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
Responsible Party Information
Patient Information Date Male Female Married Single Divorced Separated Student Last Name First Name Middle Address City State Zip E-mail Address Social Security # Date of Birth Home # Work # Cell # Employer
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
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 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
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM Please fill out this form as complete as possible. Missing information may cause a delay in receiving treatment and/or any applicable dental insurance benefits. Thank you
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
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
Name. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address
405 S. Granite Ave. PO Box 959 Granite Falls, WA 98252 tel (360) 691-7793 fax (360) 691-5577 www.cervendentistry.com To help us better serve the needs of your child and meet his/her dental healthcare needs,
HARTSELLE 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
Today s Date: / / REASON FOR INITIAL VISIT: Whom may we thank for referring you? FIRST MI LAST PREFERRED
Durga Devarakonda, DMD PLLC DD Family Dentistry Family and General Dentistry 972-245-3395 PATIENT INFORMATION PLEASE COMPLETE THE FOLLOWING FORMS TO YOUR FULLEST KNOWLEDGE. DOING SO HELPS US BETTER CARE
Welcome. We re glad you re here.
Welcome. We re glad you re here. We know that going to the dentist may not be at the top of your to do list. But whether it s been six months or six years since your last visit, we re just glad you re
TODAY S DATE: Name: Birthdate: SSN: _Married _Single _Widowed _Divorced _Separated _Other. Address: Employer: Work Phone:
WELCOME! PATIENT INFORMATION TODAY S DATE: Name: Birthdate: SSN: Home Phone: ( ) Cell: ( ) Married _Single _Widowed _Divorced _Separated _Other Address: Employer: Work Phone: Emergency contact: Phone:(
EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
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
HARTSELLE 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