Jackson Center Dental
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- Carmella Gardner
- 5 years ago
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1 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 Single Divorced Minor Other Employer/School: Occupation: Employer/School Address: Employer/School Phone: Spouse s Name: Birthday: SS#: Who is responsible for this account? Insurance Company: Subscribers Name: Group Number: SS#: Date of Birth: Is patient covered by additional insurance? Yes No Insurance Company: Subscribers Name: Group Number: SS#: Date of Birth: Assignment and Release I certify that I and/or my dependent(s), have insurance coverage with the company listed herein, and I assign directly to Northwest Dental Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Jackson Center Dental may use my health care information and may disclose such information to my insurance companies named herein and their agents for the purpose of obtaining payment for the services and determining insurance benefits or the benefits payable for related services. Please Print Name Please Sign Name Spouse s Employer: Whom may we thank for referring you? Date Relationship to Patient Phone Numbers: Home/Cell Phone: - - Work Phone: - - Emergency Contact: Name: Relationship: Phone: - - When s the best time to reach you? Dental History: Reason for today s visit: Former Dentist: Date of last dental visit: Date of last dental X-rays: Bad Breathe O Yes O No Jaw Pain O Yes O No Sensitivity to sweets O Yes O No Bleeding Gums O Yes O No Lip/cheek biting O Yes O No Sensitivity to biting O Yes O No Blisters on lips or mouth O Yes O No Loose teeth O Yes O No Smoking Cigarette/Pipe O Yes O No Burning sensation on tongue O Yes O No Mouth Breathing O Yes O No Sores in your mouth O Yes O No Chew on one side O Yes O No Mouth Pain O Yes O No How often do you floss? Clicking or popping jaw O Yes O No Ortho Treatment /Braces O Yes O No Dry mouth O Yes O No Pain around Ear O Yes O No Fingernail biting O Yes O No Periodontal/Gum Treatment O Yes O No How often do you brush? Food collection b/t teeth O Yes O No Sensitivity to cold O Yes O No Grinding teeth O Yes O No Sensitivity to heat O Yes O No
2 Health History Family Physician s Name: Date of last visit: Have you ever used a bisphosphonate medication? O Yes O No (Common brand names are Fosamax, Actonel, Atelvia, Didronel or Boniva) Have you ever taken any of the group drugs collectively referred to as fen-phen? These include combinations of Ionimin, Adipex, Fastin (brad names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). O Yes O No Please mark X if you have any of the following conditions: AIDS/HIV O Yes O No Epilepsy O Yes O No Rheumatic Fever O Yes O No Anemia O Yes O No Fainting O Yes O No Scarlet Fever O Yes O No Arthritis O Yes O No Glaucoma O Yes O No Shortness Of Breath O Yes O No Artificial Heart Valves O Yes O No Heart Murmur O Yes O No Sinus Trouble O Yes O No Artificial Joints O Yes O No Heart Problems O Yes O No Skin Rash O Yes O No Asthma O Yes O No Hepatitis Type O Yes O No Special Diet O Yes O No Autism O Yes O No Herpes O Yes O No Stroke O Yes O No Back Problems O Yes O No High Blood Pressure O Yes O No Swollen Feet/Ankles O Yes O No Bleeding abnormally O Yes O No Jaundice O Yes O No Swollen Neck Glands O Yes O No Blood Disease O Yes O No Jaw Pain O Yes O No Thyroid Problems O Yes O No Cancer O Yes O No Kidney Disease O Yes O No Tonsillitis O Yes O No Chemical Dependency O Yes O No Liver Pain O Yes O No Tuberculosis O Yes O No Chemotherapy O Yes O No Low Blood Pressure O Yes O No Tumor or Growth O Yes O No Circulatory Problems O Yes O No Mitral Valve Prolapse O Yes O No Ulcer O Yes O No Congenital Health Lesions O Yes O No Alzheimer s/dementia O Yes O No Venereal Disease O Yes O No Cortisone Treatments O Yes O No Nervous Problems O Yes O No Weight Loss O Yes O No Cough, persistent/bloody O Yes O No Pacemaker O Yes O No Are you pregnant? O Yes O No Diabetes O Yes O No Psychiatric Care/Mental Illness O Yes O No Taking birth control pills? O Yes O No Emphysema O Yes O No Radiation Treatment O Yes O No Are you nursing? O Yes O No Medications List or supply a copy of any medications you are currently taking: Pharmacy Name: Allergies O Aspirin O Barbiturates (sleeping pills) O Codeine O Iodine O Latex O Local Anesthetic O Penicillin O Sulfa O Other:
3 General Consent Form I hereby agree on this date Print Patients Full Name Today s Date to allow the doctors and staff of Jackson Center Dental to treat me for any and all necessary dental concerns that may be present now or in the future, including but not limited to: periodontal treatment (gums), prophylaxis (cleaning & exam), restorative dentistry (fillings), endodontics (root canals & pulp treatments), prosthodontics (dentures & partials), sealants (coatings on teeth), bleaching (whitening), bonding & veneers (cosmetic dentistry), Invisalign (clear braces), Nitrous Oxide (laughing gas), local anesthetic (lidocaine injection), exodontia (tooth extraction), TMJ/TMD dysfunction (jaw joint pain), radiographs (x-rays) and other general dental care. I realize I will have the opportunity to decline treatment at any time. I have read the statement above and hereby consent to treatment when and if the doctors or staff inform me that it is needed, by signing this form below. In addition, I understand that by keeping the appointment scheduled for any procedure listed or unlisted that I am giving my consent for treatment. Patients Signature Today s Date If the patient is a child or young adult under the age of 18 please sign below. Parents Signature or Guardian Today s Date
4 Our Commitment Financial Policy Jackson Center Dental is committed to the highest quality dental care possible, offering affordable services with maximum payment flexibility. Before treatment is undertaken we will consult with you so that you fully understand the need, the procedures, and the expense of your dental treatment. Together, we will implement the best plan for your dental care. In order to achieve this, we need your understanding of our payment policy. Payment Options Payment is due at the time services are rendered unless other arrangements have been made in advance. In all cases, payment in full is required at treatment completion. For your convenience, we offer the following options: 5% Cash or Check Discount Patients who pay their entire bill by cash or check at the time services are rendered (whether they have dental insurance or not) will receive a 5% reward. We will assist patients with dental insurance by filing their claim and we will instruct the insurance company to reimburse the patient directly. VISA, Master Card, Discover or American Express Dental Insurance It is important to understand our relationship is with you, not your insurance company. Additionally, our fees are the same for all patients regardless of their insurance coverage. We will present a treatment plan and an estimate of expenses, if needed, after the patient examination. Estimates are based upon available insurance information and do not guarantee payment by your insurance company. We will bill your insurance company as a courtesy; however, co-payments and deductibles are due at the time of service. Patients with dual insurance should know that they are not guaranteed 100% coverage. Fees not covered by insurance are the patient s responsibility. Care credit Financing Option Care credit is a nationally recognized credit provider that specializes in assisting individuals with financing for their dental care. Care credit provides patients with interest free payment plans as well as extended payment plans for patients who prefer more time to pay. Patients may be approved for Care credit within a couple of minutes at our office. More information about using Care credit may be obtained from the Jackson Center Dental staff. In all cases, approval for Care credit should be arranged prior to treatment Senior Reward We are pleased to extend a 5% discount to our senior patients (62 years and older) regardless of payment method. Please note that this cannot be combined with the cash discount. New Patient Emergency Appointments We request payment at the time of service for new patient emergency procedures. We will accept cash, personal checks and money orders for new patient emergency appointments. Broken Appointment Policy We anticipate that all patients will keep their scheduled appointments and we will make a reasonable effort to help them do so. However, situations do arise which may cause a patient to reschedule. We will gladly reschedule appointments, but we require 24 hours advance notice. Patients who fail to attend their appointments and have not provided us with 24 hours advance notice will be charged a $50 broken appointment fee. In addition, patients who arrive late for their scheduled appointment time may have to forfeit their appointment and may be subject to the broken appointment fee. Acceptance of Terms I have read and fully understand the above financial policies and agree to the terms outlined herein. Date (Signature of Patient or Guardian) Signature of Patient
5 Acknowledgement of Receipt of Notice of Privacy Practices * You May Refuse to Sign This Acknowledgment* I have received a copy of this office s Notice of Privacy Practices. Print Name: 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) Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations. 2010, 2013 American Dental Association. All Rights Reserved.
6 Agreement to received electronic communications Patient Name: Date of Birth: I agree that the dental practice may communicate with me electronically at the address below. I am aware that there is some level of risk that third parties might be able to read unencrypted s. I am responsible for providing the dental practice any updates to my address. I can withdraw my consent to electronic communications by calling: [ ]. Address (PLEASE PRINT Patient Signature: Date:
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
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.
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 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:
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
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:
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 THE PROVINCES DENTAL CARE
WELCOME TO THE PROVINCES DENTAL CARE Name Nickname Address Unit# Birth Date Age Sex City State Zip Single Married Widowed Other Home Phone Social Security # Work Phone Employer Cell Phone Occupation E-Mail
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
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:
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
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:
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:
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
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
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:
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
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
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
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
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
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
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
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 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
WELCOME! Patient Information:
WELCOME! Patient Information: 10220 Medlock Bridge Rd. Suite 100 Johns Creek, Ga. 30097 Name: Last First MI Mailing Address: Phone #: (C) (W) (Other) Date of Birth: SSN: Sex: Male Female Marital Status:
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 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. 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
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:
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
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 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 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 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 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,
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 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 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. 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 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
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. 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
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
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.
PATIENT REGISTRATION
TIME 10:44 AM DATE 7/12/2011 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
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 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
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 Registration
Patient Registration Patient Name: Preferred Name:_ Birth :_ Social Security #:_ Address: Street Unit # (if applicable) City State Zip Code Home Phone #: Cell Phone #: Email: Preferred method of contact?
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
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
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?
Responsible Party (if someone other than the patient)
PATIENT REGISTRATION ID First Name Last Name Chart ID Middle Initial Patient is Policy Holder Responsible Party Preferred Name Responsible Party (if someone other than the patient) First Name Last Name
Patient Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist.
Patient Profile First Name Last Name Pref. Name Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Emergency
New Patient Registration
New Patient Registration Appointment date & time: Patient Name: Birth date: SS #: Mailing Address (if different:) Phone 1: Hm Cell Wk Phone 2: Hm Cell Wk Email: Patient is a college student. Name of college/university:
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
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:
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 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
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:
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)
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
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.
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
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
Welcomes You! Patient Information. Name: Preferred name: Male Female (Last) (First) (Mi) Home Address: (Street) (City) (State) (Zip)
Welcomes You! Patient Information Today s Date: E-mail Address: I would like to receive correspondence via: e-mail text phone Name: Preferred name: Male Female (Last) (First) (Mi) Birthdate: / / Age: Social
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
Joplin Periodontics & Implant Dentistry Humaira Y. Habib, D.D.S.
Today s Date: Preferred Name: Patient Information Last Name: First: Middle: Mr. Mrs. Birth Date: Miss. Ms. / / Is that your legal name? If not, what is your legal name? Age: Sex: Male or Female Address:
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
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
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
Patient Profile. Appointment Preference. Referral Profile. Insurance Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec.
Patient Profile First Name Last Name Pref. Name of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist Home Address City State Zip Code Home # Cell # Work # Ext Occupation Email Phone # Emergency
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:
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
What to expect at your first visit
What to expect at your first visit Welcome'to'Grin.' To'save'you'time'at'your'4irst'visit,''complete'the'following'forms'before'you'arrive'for'your'appointment.''' ' ' ' The'typical'initial'visit'consists'of'the'following:'
Welcome to Metropolitan Dental Care
Welcome to Metropolitan Dental Care Personal Information Date_ First Name Last NameMiddle Initial Preferred Name Address City, State, Zip Home Phone Work Phone_Cell Phone Male Female Minor Single Married
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
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:
117 FLORAL VALE BLVD, YARDLEY, PA PHONE: FAX: PATIENT INFORMATION
117 FLORAL VALE BLVD, YARDLEY, PA -19067 EMAIL: radiantsmiles2009@yahoo.com PHONE: 215-860-4600 FAX:215-860-1455 PATIENT INFORMATION Patient s Name: (Last) (First) (MI) Address: (Street/Apt.) (City) (St)
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:
PERSONAL HISTORY. Spouse s Name:
PERSONAL HISTORY Date: Patient Name: Address: Zip Code: Sex: Marital Status (circle one): S M D W Sep Spouse s Name: Date of Birth: / / Social Security Number: - - Employer: Home Phone: Cellular Phone:
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.
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 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
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
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
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
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
REGISTRATION FORM Section I: Patient Information. Date: Name: SSN: - - Date of Birth:
REGISTRATION FORM Section I: Patient Information Date: Name: SSN: - - Date of Birth: Address: City: State: Zip: Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Minor Single Married Widowed Separated Divorced
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
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:
New Patient Paperwork
New Patient Paperwork Patient Information: Patient Name: DOB: Home Address: City: State: Zip Code: Home #: Cell #: E-Mail: @. Would you like to receive text messages and/or emails as appointment reminders?
9521 US Hwy 290 West, Suite 103 Austin, TX (512) PATIENT INFORMATION
9521 US Hwy 290 West, Suite 103 Austin, TX 78737 (512) 888-9453 PATIENT INFORMATION Please Circle Title: Dr. Mr. Mrs. Miss Name: First M Last I prefer to be called: Male Female Birthdate: Age: _ SSN #
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,
Patient Information. Patient s Name: Preferred Name: Date of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status:
Patient Information Today s Patient s Name: Preferred Name: of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status: Employer: Occupation: Spouse s Name: Spouse Employed by: Business Phone: