o Bad Breath o Grinding Teeth o Sensitivity To Hot
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- Alexandrina Bates
- 5 years ago
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1 REGISTRATION AND TREATMENT I PATIENT INFORMATION Name Sc. Sec. # LAST FIRST MIDDLE IN. Address City State Zip Hme Phne Cell Phne Sex OM OF Age Birth Date Single Married Widwed Child Divrced Patient Emplyed By Occupatin Business Address Whm may we thank fr referring yu? In case f emergency wh shuld be ntified? Phne Persn Respnsible fr Accunt PRIMARY INSURANCE Business Phne LAST FIRST MIDDLE IN. Relatin t Patient Birth Date Sc. Sec. # Address (if different than patient's) Phne City State Zip Persn Respnsible Emplyed By Occupatin Business Address Business Phne Insurance C. & Address Grup # Persn Respnsible fr Accunt SECONDARY INSURANCE LAST FIRST MIDDLE IN. Relatin t Patient Birth Date Sc. Sec. # Address (if different than patient's) Phne City State Zip Persn Respnsible Emplyed By Occupatin Business Address Business Phne Insurance C. & Address Grup # DENTAL HISTORY Reasn fr Tday's Visit Frmer Dentist Address Date f Last Dental Care Date f Last Dental X-Rays Check (t/) if yu have had prblems with any f the fllwing. Bad Breath Grinding Teeth Sensitivity T Ht Bleeding Gums U Lse Teeth Or Brken Fillings Sensitivity T Sweets Clicking Or Ppping Jaw Peridntal Treatment Sensitivity When Biting Fd Cllectin Between Teeth Sensitivity T Cld Sres Or Grwths In Yur Muth Hw ften d yu flss? Hw ften d yu brush?
2 Tme 10:15 AM Date 12/8/1015 Paradigm Dental Of Beavertn Eaglesft Medical Histry Bith Date: Patient Name: Date Created: Althugh dental persnnel prinarily treat the area ii and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be takilg, culd have an imprtant ilterrelationship with tile dentistry yu wid receive. Thank vu fr GOswerng the fllwing questins. Are yu under a physician's care nw? Have yu ever been hspitalized r had a majr pertin?.,' Are yu taking any medicatins, - ~ Have yu ever had a serius head r neck injury? - YeS-' pills, r drugs? D yu take, r have yu taken, Phen-Fen r Redux? ~ves~i======================================~j If yes' ffyes~, ================:~=========== -~ '~.' -,.-. Nt> Have yu ever taken Fsamax, srnva, Actnel r any ther medicatins cntaining bisphsphnates? J If yes...~.' Are yu n a speal diet?,':'. D yu use tbacc?.:, ==================~~===.~~ If yes i Wmen: Are yu ':.; PregnanVTrying '"...;Nursing? t get pregnant? [J Taking ral cntrnceptlves? Are yu alergic t any f the fllwing? Cl Penicillin.: Aspirin.-:: Metal D yu use cntrlled substances?,~ Other? C If yes Ifves 1 D yu have, r have yu had, any f the fllwing? "" AIDS{HlV Psitive Crtisne Medicine ~. - C NQ Ves.: = Ves - Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gut ArtifiCial Heart Valve '::', ~., DAcrylic.j Lcal Anesthetics C:Cdeine i.":: Sulfa Drugs ::"i latex Diabetes Drug Addictin. Emphysema Epilepsy r Seizures, Easily Winded _ Hemphilia -,~ HepatitiS A HepatitiS B r C Herpes High Bld Pressure High Chlesterl Rash ExcessiVe Bleeding " Excessive Thirst Hypglycemia Fainting Spelis/DiZZi1ess -, Bleed DiSEase ' Frequent Cugh Irregular Heartbeat Kidney Prblems Bld Transfusin Frequent Diarrhea Breathing Prblems ', Frequent Headaches ' Bruise Easily ' NO Genital Herpes Cancer vss. " Artificial JOint Asthma = Chemtherapy -.,1'40 Chest Pains Cld Sres/Fever Blisters -- -, Cng"f'Iitai He",t Disrder ~, Cnvulsins Yellw Jaundice '-, Glaucma Hay Fever Heart Attllck/Failure ' Heart Murmur Heart Pacemaker Heart Truble/Disease ' Have yu ever had any serius illness nt listed Hives r Radiatin Treatments.,~. Recent Weight lss ', rj,,:..:, ::, -, -, Ye, liver Disease ". lw Bld Pressure Lung Disease leukemia Mitral Valve Prlapse ves', OsteprSis :,~ Pain in Jaw Jints ParathyrOid Oisease.~. Na Psych iatric Care,", If yes i--.. ~,= Renal DialysiS ':/ ~_ Rheumatic Fever,-. ~ Rheumatism " Scarlet Fever :: Shingles :' Sickle Cell Disease Sinus Truble Spina Bifida Ves Stmach/lntesti'lal Disease,~, - -: Strke." -... Swelling f limbs Thyrid Disease. Tnsillitis Tuberculsis Tumrs r Grwths Ulcers Venereal Disease " :~. -, Nt>. = -"~ =:J Cmments: I -_._--. --_._ ~-., , T the best f my knwledge, the questins n this frm have been accurately answered. I understand that prviding ncrrect infrmation can be dangerus t my (r patient'$) health. It is my respnsiliity t infrm the dental ffice f any changes in medical status. Signaturef Patient, Parent r Guardian: x Date: _
3 Paradigm Dental f Beavertn Financial Plicy All accunts are due and payable at the time f yur visit, unless satisfactry arrangements have been made prir t yur treatment. There will be a 5% discunt fr accunts paid in full n the date f service. We have utside financing available thrugh Care Credit, hwever, we cannt ffer a discunt with this payment plan. We wrk with mst insurance cmpanies and always try t maximize yur cverage thrugh meticulus detailing f prcedures and interactin with yur insurer. We electrnically send yur claim frms and we're available t answer any questins we can. Insurance is gladly billed as a curtesy t r patients, when yu prvide us with the current infrmatin and necessary frms. Even thugh yu may have an insurance claim pending, yu will receive a mnthly statement fr the utstanding balance n yur accunt. We cannt accept respnsibility fr cllecting an insurance claim after 60 days r fr negtiating a disputed claim. Insurance reimbursement is a cntract between yu, yur emplyer and the insurance carrier. Yu are respnsible fr the payment f yur accunt. On accunts which have a balance, the payment is due upn receipt f the mnthly statement. Any balance utstanding fr mre than 90 days, will bear interest at 18 % per annum r 1.5 per mnth. There will be a charge fr any brken appintment r appintment cancelled and rescheduled with less than a 2 business day ntice. The length f time scheduled fr yu will determine the charge with $45.00 being the minimum charge. We will nt reschedule any patient after tw appintments bave been missed. HAVE READ THIS FINANCIAL POLICY AND UNDERSTAND THAT REGARDLESS OF ANY INSURANCE COVERAGE I MAY HAVE, I AM RESPONSILBE FOR PAYMENT OF MY ACCOUNT. I UNDERSTAND THAT DELINQUENT ACCOUNTS MAY BE ASSIGNED TO A CREDIT REPORTING COLLECTION SERVICE. IF IT BECOMES NECESSARY TO EFFECT COLLECTIONS OF ANY AMOUNT OWED ON COSTS AND EXPENSES, INCLUDING REASONABLE ATTORNY FEES. I HEREBY AUTHORIZE THE DOCTOR TO RELEASE INFORMATION NECESSARY TO SECURE PAYMENT. SIGN D,ATE _
4 Paradigm Dental f Beavertn SW Beavertn-Hillsdale Hwy. Beavertn, Oregn *Yu May Refuse t Sign This Acknwledgement* ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, -J Privacy practices. have received a cpy f this ffice's tice f Please Print Name Signature Date Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Privacy Practices, but Acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining the acknwledgement Other (Please Specify)
5 Paradigm Dental f Beavertn, LLC Duglas A. Rust DMD Brian T. RustDMD SW Beavertn-Hillsdale Hwy. Beavertn, OR (503) Fax (503) Release f Recrds Patient name(s):. DOB: _ I hereby request and give my permissin t: Previus Dentists Name: Phne number: ' T release all x-rays and pertinent dental infrmatin t: Paradigm Dental f Beavertn, LLC Paradigm.dana11@gmail.cm Sign: Date: _
6 NOTICE OF PRIVACY PRACTICES 'rnrs NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO TmS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicablefederal and state law t maintainthe privacy f yur health infrmatin. We are als required t give yu this tice abut ur privacypractices, ur legalduties, and yur rights cncerningyur health infrmatin. We must fllw the privacy practices that are described in this ticewhile it's in effect. This tice takes effect , and will remain in effect until we replace it. Wereserve the right t changeur privacypractices and the terms f thistice at any time, prvided such changes are permitted by the applicablejaw. Wereserve the right t make the changes in ur privacypractices and the new terms f ur tice effective fr all health infrmatinwe that we maintain, includinghealth infrmatinwe created r receivedbefre we made the changes. Befrewe make a significant change in ur plicy practices, we will changethis tice and makethe new tice available upn request. Yu may request a cpy f ur ticeat any time. Fr mre infrmatin abut privacypractices, r fr additinalcpies f this tice, please cntact us by using the infrmatinlistedn the bttm f this tice. USES AND DICLOSURES OF HEALTH INFORMATION We use and disclse health infrmatin abut yu fr treatment, payment, and healthcare peratins. Fr example: treatment t yu. Treatment: YOU. Payment: We may use r disclse yur health infrmatin t a physician r ther healthcare prvider prviding treatment t We may use and disclse yur health infrmatin t btain payment fr the service we prvide yu. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur bealthcare peratins. Healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence f qualificatins f healthcare prfessinals, evaluating practitiner and prvider perfrmance, cnducting training prgrams, accreditatins, certificatins. licensing r crcdentialing activities. Yur Authrizatin: In additin t ur use f yur health histry fr treatment, payment r healthcare peratins, yu may give us written authrizatin t use yur health infrmatin r t disclse it t anyne n purpse. If yu give us an authrizatin, yu may revke it in writing at any time. Yur revcatin will nt affect any use r disclsures permitted by yur authrizatin while it was in effect. Unless yu give us written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this tice. T Yur Family and Friends: We may use r disclse health infrmatin t yu, as described in the Patient Rights sectin f this tice. We may disclse yur health infrmatin t a family member, friend r ther persn t the extent necessary t help with yur healthcare, but nly if yu agree that we may d s. Persns Invlved in Care: We may use r disclse health infrmatin t ntify, r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representative r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu an pprtunity t bject t such used r disclsures. In the event f yur incapacity r emergency circumstances, we will disclse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn's invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable interferences f yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x-rays, r ther similar frms f health infrmatin. Marketing Health Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Abuse r Neglect: We may disclse yur health infrmatin t apprpriate authrities if we reasnably believe that yu are a pssible victim f child abuse, neglect, r dmestic vilence r the pssible victim f ther crimes. We may disclse yur health infrmatin t the extent necessary t avert a serius threat t yur health r safety r the health r safety f thers.
Patient Information. Personal Information. Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married
Patient Infrmatin Welcme t Art f Dentistry! We will always d ur best t earn the trust that yu have placed in us. Please fill ut these frms. Persnal Infrmatin Patient s Full Name: f Birth: Address: Preferred
STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION
PATIENT INFORMATION Patient Last Name: First: MI Preferred Name: Sex: M F Birth Date: Marital Status: Scial Security N.: Street Address: City: State: Zip: Hme Phne: Wrk: Cell: Email: Preferred Cntact Methd:
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. May Refuse to Sign This Acknowledgement-
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES -Yu I, Privacy Practices. May Refuse t Sign This Acknwledgement- ---, have received a cpy f this ffice's Ntice f {Please
Patient Information. Child s Name Birthdate Gender M F. Nickname SS# Responsible Party Name Relationship
Patient Infrmatin Date Child s Name Birthdate Gender M F Nickname SS# Respnsible Party Name Relatinship Address, Email address Hme Phne Cell Phne Wrk Phne Name f Schl Hbbies Whm may we thank fr referring
Main Phone #: ( ) - Secondary Phone # :( ) -
Patient Infrmatin Email: Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm
PERSONAL. Guarantor Name Last First MI (Preferred)
PATIENT INFORMATION We are pleased t welcme yu t ur ffice. Please take a few minutes t fill ut this frm as cmpletely as yu can. If yu have any questins we ll be glad t help yu. PERSONAL Patient Name Last
Welcome to Lowcountry Family Dentistry!
Welcme t Lwcuntry Family Dentistry! Patient Medical and Dental Histry Frm Please take a few minutes t carefully read ver and answer the fllwing questins t help us treat yu safely. If yu have any questins,
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:
Bernard W Lynch, DMD, FAGD
Bernard W Lynch, DMD, FAGD Dental Care Burke 703.596.1555 9239 Old Keene Mill Rad Burke VA 22015 NEW PATIENT INFORMATION Patient Name: Date: Please answer the fllwing cmpletely and thrughly: 1. What specifically
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 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
PATIENT REGISTRATION. Middle Initial: Last Name: Address: City, State, Zip: Home Phone ( ) Work Phone: ( ) Cell Phone: (_)
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address: City, State, Zip: Hme Phne ( ) Wrk Phne: ( ) Cell Phne: (_) Birth Date: Age: Sex: Male r Female Scial Security Number: Occupatin: Emplyer:
CONSENT FOR TREATMENT
Thank yu fr chsing 2 nd Street Dental, LLC as yur dental prvider. We are cmmitted t yur treatment being successful. Please understand that payment f yur fees is cnsidered part f yur treatments. The fllwing
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 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. 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:
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: 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
Patient Information. Date: Last First MI
1320 South Lapeer Road Lake Orion, Michigan 48360 (248) 693-6213 Patient Information Patient Name: Date: Last First MI Male Female Married Single Child Other Birth Date: Social Security #: Driver s License
PATIENT REGISTRATION
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 to The Kids Dentist NEW PATIENT FORMS
TODAY S DATE Welcme t The Kids Dentist NEW PATIENT FORMS CHILD S FIRST NAME MI LAST NAME PREFERRED NAME: MALE FEMALE DATE OF BIRTH - - AGE ADDRESS CITY STATE ZIP PLEASE LIST IN ORDER THE BEST NUMBERS TO
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
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:
Home Phone ( ) Cell Phone ( ) Have you ever been a patient of our practice? Yes No. Medical Doctor Phone ( ) Marital Status Spouse s Name
WELCOME TO OUR PRACTICE PATIENT INFORMATION Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Sex: Male Female Birth Date Age Sc. Sec. # E-mail Street City State Zip Cde Hme Phne ( ) Cell Phne ( ) Have
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
Preferred Name: First Name: Last Name: Middle Initial: Work Phone: Ext: Cellular:
TIME PATIENT REGISTRATION DATE ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party ( if someone other than the patient ) Last Name: Preferred Name: Middle Initial: First
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. MyIdealDental.com. Primary insurance information. Secondary insurance information
Patient registration Patient ID Chart ID Medicaid ID Employer ID First Name Last Name Member ID Carrier ID Preferred Name Middle Initial Patient is: Primary policy holder Responsible Party is: Primary
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:
Todd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics
Todd Jorgenson. D.M.D" M.S. Practice Limited to Periodontics 3048 E Baseline Rd. Ste. 112 Mesa, Arizona 85234 Telephone: 480-558-4500 Fax: 480-827-9703 PATIENT INFORMATION Today's Date Name Social Security
FINANCIAL POLICY. Policy Regarding Minor Children
FINANCIAL POLICY We are committed to providing you and your family with the best possible care. In order to achieve these goals, we need your assistance and your understanding of our policy regarding payment
Patient Registration
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: Patient is: Policy Holder Responsible Party Address: City State/Zip Home Phone: Cell Phone: Work Phone: Sex: Male Female Marital
Patient Information. Date: Last First MI
1320 South Lapeer Road Lake Orion, Michigan 48360 (248) 693-6213 Patient Information Patient Name: Date: Last First MI Male Female Married Single Child Other Birth Date: Social Security #: Driver s License
PATIENT 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:
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:
SCARLET DENTAL, KATIE VINCER SEARS DDS, INC. Tel:
PATIENT INFORMATION Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT,
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?
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?
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
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:
Street Address City State Zip. Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor Separated Divorced
PATIENT REGISTRATION AND MEDICAL HISTORY First Name: Last Name: Middle Initial: Preferred Name: Street Address City State Zip Home Phone: Work Phone: Ext: Cell: Sex: M F Age Married Widowed Single Minor
L. JASON PAYNE, D.M.D., P.C.
L. JASON PAYNE, D.M.D., P.C. PATIENT REGISTRATION First Name: Last Name: Middle Initial: Patient Is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient)
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
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
White Rock Dental. Periodontal Treatment (Deep Clean) Bleeding Gums. Sensitivity of your teeth to heat or cold Clicking/Popping jaw joints
Patient Information: (All Fields Required) Date: Legal First Name: Last: MI: Preferred Name: Date of birth: SSN: Address: Apt? No Yes: Apt #: City/State: Zip: Email: Home Ph: Cell: Prefer Contact By: Call
EXAMINATION. Business _... Date of birth.. Person responsible for payment of this account... HEALTH HISTORY
EXAMINATION Date..._. Patient's name. Address:......_..... Telephne: Hme Nickname _......._........ Business.......... Business _....... Patient emplyed by. ~......._... Psitin._..._. Psitin held hw lng........._
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
MartinDental. Welcome to
Welcome to MartinDental We want you to have the most relaxing and comfortable experience possible with us. Help us get to know you by answering the following questions. Thank you! When I think about coming
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
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:'
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
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 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?
Name DOB / / Age Sex First Middle Last Address City State Zip. Driver s License State SSN
CHART NO. Welcme t DHC! :) Welcme t ur ffice. We appreciate the cnfidence yu have placed in us t prvide yu with ral health services. T assist us in serving yu, please cmplete the fllwing frm. The infrmatin
Macon County Health Department Dental Clinic
Macon County Health Department Dental Clinic 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
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:
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
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
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
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
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 #
Please do not hesitate to call us if we can answer any questions about these forms or your first visit with us.
Welcome to our Practice! We are delighted that you have selected our office for your dental care. To assist us in providing you with excellent service, please take a few minutes to print the enclosed forms
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
tvcle EXPRESSIONS Phone: (727) 78-SMILE Looking forward to seeing you!
I DR. LYNDSAY H. MCCASLIN Cosmetic & Family Dentistry Phone: (727) 78-SMILE 727-787-6453 oo so U. af c =3 < 2 Thank you for choosing our dental practice. We look forward to meeting you, and giving you
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
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
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
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
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
17183 I-45 S, Suite 410 The Woodlands, TX (281) / (281) Fax PATIENT INFORMATION
17183 I-45 S, Suite 410 The Wdlands, TX 77385 (281) 602-7380 / (281) 602-7386 Fax PATIENT INFORMATION Date: Name: DOB: Scial Security #: Address: City/State/Zip: Hm # Wrk # Cell # Emplyer: Email: Hw did
Meds Yes No. Joshua F. Maxwell, D.D.S Dallas Pkwy, #100 Frisco TX First Name Middle Initial. Address City State/Zip
Allergies Yes No Meds Yes No Premed Yes No Preferred Pharmacy Info: Joshua F. Maxwell, D.D.S. 11955 Dallas Pkwy, #100 Frisco TX 75033 469-633-0550 Patient information First Name Middle Initial Last Name
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 Registration/Financial Policy
Patient Registration/Financial Policy Date: Patient Information First Name: Last Name: Middle Initial: Preferred Name: Parent/Legal Guardian(s) if under the age of 18: Address: City: State: Zip: Home Phone:
Child Health and Dental History Form
3205 SE 192 nd Ave Suite 100, Vancuver WA 98683 Office 360-891-9283 Fax 360-891-9283 www.undertheseakidsdentist.cm Child Health and Dental Histry Frm Child s Name: DOB Address: Phne# Gender: Male Female
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
Patient Information Sheet Date: Chart ID: Whom may we thank for referring you?
Patient Information Sheet Date: Chart ID: Whom may we thank for referring you? First Name: Driver License: Last Name: SSN: Middle Initial: Preferred Name: E-mail: Gender: o Male o Female Please circle:
Today's Date: (MM/DD/YEAR) / /20
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
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 Registration Montgomery Dental Arts
Patient Registration Montgomery Dental Arts Patient s First Name: Middle: Last: Preferred Name: of Birth: Patient is covered by dental insurance: / Patient is the person responsible for payment: / Address:
TfeTaCma DentaQ LXJZ Michael DePalma, DDS Errin DePalma, DDS. 500 Franklin Avenue, Unit 3 Berlin, MD , P
Conf i r m appoi nt mentby : Emai l Phone T ex t SMILE SURVEY YES NO Do you like to smile and show your teeth? Are you happy with the way your teeth look? Do you have unsightly crowns or fillings? Are
First Name Last Name Middle Initial. City State ZIP. Birth Date: SS#: Driver s Lic#: State:
DATE PATIENT ACCOUNT NO PatientRegistration PATIENT S FULL NAME Policy Holder Responsible Party RESPONSIBLE PARTY (if someone other than the patient) First Name Last Name Middle Initial City State ZIP
Jennifer Q. Le, DMD, D-ABDSM, CPCC, ACC Diplomate of American Board of Dental Sleep Medicine. Dental Patient Registration
Dental Patient Registration Patient Information First Name: Middle: Last: How did you hear about us? Preferred Name: Address: City, State, Zip: Home Phone: Work Phone: Ext: Cellular: Email address: By
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
PATIENT REGISTRATION. First Name: _ Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: _. Address: _ Address 2: _
TIME 145 PM DATE 10/13/2008 10: Chart 10: PATIENT REGISTRATION First Name: _ Last Name: Middle Initial: Patient Is: D Policy Holder Preferred Name: _ o Responsible Party Responsible Party (Wsomeone other
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
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
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)
Referred By Phone. Pharmacy Name, Location & Phone #
3150 E. 41 st St., Suite 131, Wellington Square Building Tulsa, Ok 74105 (918) 749-1639 Fax (918) 749-0416 info@midtownsmilestulsa.com Patient Information Patient Name Address City State Zip Date of Birth
REGISTRATION FORM HISTORY Patient Information
REGISTRATION FORM HISTORY Patient Information Name: of Birth SS # Home phone # ( ) Cell phone # ( ) Address Apt. # City State Zip Driver s License # State Email Address: Check Appropriate Box: Minor Single
o TV CHANNEL o VAlPAK o PATIENT REFERRAL NAME o SAVE ON EVERYTHING (SMALL BOOKLET) o OTHER (PLEASE BE SPECIFIC) o INTERNET PATIENT INFORMATION DATE:
PATIENT INFORMATION DATE: NAME: DATE OF BIRTH: EMAIL: ADDRESS: CITY: STATE: ZIP: HOME: CELL: WORK: EMERGENCY: MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SOCIAL SECURITY NUMBER: SEX: MALE FEMALE NAME
Patient Registration Form
Patient Registration Form Patient Name: Date of Birth: SS #: Driver s License: Address: City/State/Zip: Name of Insured: Insured SS#: Insured DOB: Relation to Patient: Spouse Parent Other Employer: Position
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,
PARENT/GUARDIAN INFORMATION
Ahmadi & Alvand, DDS, PA General, Cosmetic and Implant Dentistry PATIENT INFORMATION Full Name Preferred Name Address City State Zip code Home Phone Number Work Cell phone Language Sex Marital Status:
You can get help from government organizations that are not connected with us
2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) BACKGROUND SECTION 1 Intrductin Sectin 1.1 What t d if
REPRESENTATIVE PAYEE PROGRAM T. O. D., Inc.
P.O. Bx 99243 Referral Checklist Client Infrmatin: Please cmplete t the best f yur ability adding as many details as available. Budget: The budget shuld be filled ut as cmpletely as pssible. If yu are
Primary Insurance. Insurance Group # Insurance Phone # Please present your Insurance Card and Driver's License to the receptionist to be photocopied*
Today's Date: (MM/DD/YEAR) / /20 Circle One: Dr. Mr. Mrs. Ms. Miss. First: Middle: Last: Jr. Sr. Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email Address: May we Contact you by Email?
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
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
CRG PATIENT REGISTRATION FORM
CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Scial Security Number: Male: Female: Hme Address: (Street / RR Bx # / Apt. #) (City/State) (Zip) Preferred