dental health associates, L.L.P.
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- Theodore Thornton
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3 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 you for choosing us to provide your dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and up front. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff. DENTAL INSURANCE As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following: You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim. Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you and not your insurance company. You are responsible for our fees and not what your insurance company allows or considers usual, customary and reasonable all of which vary from one company to another. Although we may estimate your insurance benefits we are not responsible for their accuracy. Knowledge of benefits as well as benefits amounts, limitations, exclusions, waiting periods, etc. is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate. PAYMENT POLICY We accept cash, personal checks, debit cards, Visa, MasterCard, American Express and Discover. For those who qualify, we also accept Care Credit. After dental insurance has paid its portion, a statement is sent to the mailing address on record, for the remaining balance. Payment is expected within 25 days of the statement date to avoid finance charges. If the insurance company does not pay in full within 45 days, it will be your responsibility to pay the balance due within 2 weeks. PATIENTS WITHOUT INSURANCE COVERAGE We provide written estimates of fees, and payment is expected at each visit for services rendered. MINOR PATIENTS The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at the visit. milton: 20 School House Road, Milton, Pennsylvania
4 RETURNED CHECKS A $30 charge applies when a check is returned by the bank FINANCE CHARGES AND COLLECTION FEES A finance charge will be applied to all balances not paid within 30 days of the monthly billing date. Finance charges will be assessed each month until paid. It is your responsibility to ensure your insurance company pays promptly so you can avoid finance charges. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. We understand temporary financial problems may affect timely payment of your balance. In those situations, we encourage you to communicate any such problems immediately so we may assist you in the management of your account. OVERDUE BALANCE An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: attorney fees, court fees and any other fees associated with the collection of your debt. BROKEN OR MISSED APPOINTMENTS Appointments not kept or changed with less than 24 hours notice are considered broken. Broken appointments prevent others from receiving the dental care they deserve. We take them seriously so please be considerate and inform us in advance if you need to change your appointment. If you show a history of broken appointments or no shows a warning will be given. This warning will be documented. After your warning, if you fail to give the required notice or do not show to your appointment, you may be dismissed from our services. RECORDS AND REIMBURSEMENTS Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs for a nominal duplication fee. CONSENT & AUTHORIZATION I HEREBY DO AUTHORIZE DENTAL TREATMENT AND AGREE TO PAY ALL RELATED PROFESSIONAL FEES. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety, outlining office policies and financial policies of Susquehanna Valley Dental Health Associates. Without any reservations, I agree to abide by the policies outlined herein. FORM COMPLETED BY: Printed Name Signature IN CASE OF A CHILD: Relationship to child Date Are you the person legally responsible for this child? Yes No Reviewed by staff member Date
5 susquehanna valley dental health associates, L.L.P. "Creating smiles is our business." ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowlegement* I, have received a copy of this office s Notice of Privacy Practices. Patient Name Guardian 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)
6 NAME LAST FIRST M.I. Have you ever had any of the following? Y N AIDS/HIV+ Y N EXCESSIVE BLEEDING Y N TUMORS Y N EPILEPSY Y N GLAUCOMA Y N NERVOUS DISORDERS Y N PREGNANCY Y N ULCERS Y N ANEMIA Y N HAY FEVER DUE DATE: Y N TUBERCULOSIS Y N ALLERGIES Y N FAINTING Y N MENTAL DISORDERS Y N DIZZINESS Y N HEAD INJURIES Y N VENEREAL DISEASE Y N CANCER Y N ARTHRITIS Y N HEART DISEASE Y N RADIATION TREATMENT Y N JAUNDICE Y N ARTIFICIAL JOINTS Y N HEPATITIS Y N RHEUMATIC FEVER Y N BLOOD DISEASE Y N ASTHMA TYPE Y N RHEUMATISM Y N HEART MURMUR Y N KIDNEY DISEASE Y N HIGH BLOOD PRESSURE Y N STOMACH PROBLEMS Y N DRUG/ALCOHOL ABUSE Y N DIABETES Y N SINUS PROBLEMS Y N SEIZURE/SEIZURE DISORDER Y N MITRAL VALVE PROLAPSE Y N RESPIRATORY PROBLEMS Y N LIVER DISEASE Y N STROKE Are you allergic to any of the following? Y N ASPIRIN Y N CODEINE Y N DENTAL ANESTHETICS Y N ERYTHROMYCIN Y N LATEX Y N PENICILLIN Y N TETRACYCLINE Y N OTHER Please list any other drugs/materials/foods that you are allergic to: Name of Physician: Phone: Has your doctor told you that you require antibiotics before dental treatment? Yes No Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain: Are you now under the care of a physician? Yes No If yes, please explain: Do you have any health problems that need further clarification? Yes No If yes, please explain: Do you use tobacco products? Yes No If yes, what products? Please list current medications that you are taking (prescription/over the counter). To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. Date:
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. 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:
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
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
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.
Glacier Dental 2421 E Tudor Road Suite #101 Anchorage, AK 99507
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
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
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.
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
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
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
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):
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
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
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
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#
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
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
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
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
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
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
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
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
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:
Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
247 River Vista Place Suite 200 Twin Falls, Idaho 83301 www.twinfallssmiles.com (208) 734-8080 PATIENT REGISTRATION Name: Preferred Name: Address: Home Phone: Work Phone: Cell Phone: Email: Can we contact
Name: 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
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
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
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
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 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:
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
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
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
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
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:
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 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
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
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
Your visit with us will consist of meeting our team, taking a tour of our office, and a comprehensive exam with Dr. Koch.
Welcome to our family of fine patients and thank you for selecting us as your personal dental care team. We will always strive to make your relationship with us as pleasant and rewarding as possible. Your
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 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
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
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
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
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 {
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
Patient Information & 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 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:
ADULT PATIENT INFORMATION. Gender: Male/Female. Patient s name Last First Middle Residence Street City Zip Mailing Address Street City Zip
ADULT PATIENT INFORMATION Date Gender: Male/Female Patient s name Last First Middle Residence Street City Zip Mailing Address Street City Zip Home Phone: Work Phone: Cell Phone Birthdate Social Security
PATIENT REGISTRATION Today s Date:
FLYNN Dental Group Westside: 904-551-3083 PATIENT REGISTRATION Today s Date: Middleburg: 904-282-5025 Patient Name Sex: M F Birthdate Age Home Address City State Zip Please Your Circle One: Single Married
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
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:
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,
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
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:
Drs. Ellis, Green and Jenkins
Drs. Ellis, Green and Jenkins WELCOME TO OUR PRACTICE Patient Information Today s : First Name: MI: Last Name: _ Birthdate: Age: SS#: _ Marital Status: Married Single Widowed Divorced Separated Address:
Patient Information. Health History
Patient Name: Patient Information Last, First MI (Preferred Name) Date: male female single married child other Social Security_ Birth Date // State ID/TXDL# Phone (Home): (Work) Ext:_ (Cell) (Preferred#)
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:
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: 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
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
Name Relationship Did you hear about us in any other way?
PATIENT INFORMATION Personal Information Patient s Name Today s Date Nickname/Preferred Name (if any) Birth date S.S. # - - Status (please circle) Child / Adult Single Married Divorced Widowed Parent s/spouse
PATIENT REGISTRATION
PATIENT REGISTRATION Name: Date: First MI Last Preferred Name: RESPONSIBLE PARTY: (if someone other than the patient) First Name: Last Name: Middle Initial: Address: City: State: Zip: Home #: Work #: Ext:
Patient 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
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
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 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
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
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:
Family Dentistry ANDREW P MINIGH DDS
PATIENT INFORMATION: Family Dentistry ANDREW P MINIGH DDS First Name: Last Name: Middle Initial: Address: City: State/Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security # Driver s
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
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:
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
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
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. 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:
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 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
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.
Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283
Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283 Thank you for visiting Tempe Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
Insurance Information
About You Today s Date: Name: Last First M.I. I prefer to be called: Birthdate: / / S. S. #: - - Drivers License: State Number Street Address: and Street City State Zip Mailing Address: P. O. Box City
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
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
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:
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
Jackson Center Dental
Patient Information Jackson Center Dental Insurance Information Date: Social Security#: Patient Last Name: Patient First Name: Address: City: State: Zip Code: Sex: o Male o Female Birthday Date: Age: Married
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:
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)
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
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
Your address: Emergency Contact Name: Emergency Contact Phone: PATIENT INFORMATION. Sex. Name of Spouse or Partner Names of Children (if any)
Date of First Office Call: Last Name Legal 1 st Name Middle Name Mail Address City State Zip Secure Phone # PATIENT INFORMATION Date of Birth Sex Marital Status Occupation Name of Spouse or Partner Names
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
SSN: DOB: Cell Phone: Home Phone: Work Phone: Preferred method of contact: Address: Employer: Occupation: Widowed. Divorced
2960 Professional Park Drive, Burlington, NC 27215 (336) 228-8159 office (336) 226-1936 fax www.alamancefamilydentistry.com info@alamancefamilydentistry.com Name: Last First MI Title Preferred Name: Male
Patient Information. Date of Birth Social Security # Primary Contact Number? Home Cell Work. Dental History. Reason for today s visit
Patient Information Michael G. Paat, DMD First name Middle Initial Last name Address City State ZIP Date of Birth Social Security # Home phone Cell phone Work phone Primary Contact Number? Home Cell Work
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
BRANDON D. HENDERSON, DMD 425 E. Tabernacle Street, St. George, UT 84770
BRANDON D. HENDERSON, DMD 425 E. Tabernacle Street, St. George, UT 84770 PATIENT Name (First) (Last) Mr. Mrs. Ms. Dr. Preferred Name Birthdate SS# - - Home Address City State Zip Minor Single Married Divorced