Home Phone ( ) Cell Phone ( ) Have you ever been a patient of our practice? Yes No. Medical Doctor Phone ( ) Marital Status Spouse s Name
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- Ellen Moody
- 6 years ago
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1 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. # Street City State Zip Cde Hme Phne ( ) Cell Phne ( ) Have yu ever been a patient f ur practice? Yes N Medical Dctr Phne ( ) Marital Status Spuse s Name Emplyer Bus Phne ( ) PAYMENT AND INSURANCE INFORMATION Wh will be respnsible fr this accunt? Self Spuse Father Mther Other (If self, skip t next sectin) First Name Last Name S.S. # Phne Street City State Zip Cde Emplyer Bus. Phne ( ) Student: Full Time Part Time Schl Name Married Divrced Legally Separated Widw Single Emplyed: Full Time Part Time Retired Hmemaker PRIMARY DENTAL INSURANCE COMPANY Emplyer Bus. Address _ Bus. Phne ( ) Ins. C. Name Bus. Address Bus. Phne ( ) Grup # Grup Name Insured Party Relatinship t insured Birth Date S.S.# Address Phne ( ) I.D.# SECONDARY DENTAL INSURANCE COMPANY Emplyer Bus. Address _ Bus. Phne ( ) Ins. C. Name Bus. Address Bus. Phne ( ) Grup # Grup Name Insured Party Relatinship t insured Birth Date S.S.# Address Phne ( ) I.D.# DENTAL HISTORY Date f last dental visit Name f previus dentist Phne ( )
2 HEALTH HISTORY T ur family f patients: Althugh dentists primarily treat the area in and arund yur muth, yur muth is part f yur entire bdy. Health prblems that yu may have r medicatins that yu are taking have an imprtant interrelatinship with the dental care yu will be receiving. There is a serius relatinship between peridntal (gum) prblems and heart disease. Thank yu fr answering the fllwing questins. Yur answers are fr ur recrds and will be cnsidered cnfidential. Reasn fr tday s ffice visit. Yes N 01. Have yu had any changes in yur general health in the past year? Are yu under the care f a physician? Date f last visit If s, fr what are yu being treated? 03. Have yu had any illness, surgery r been hspitalized in the past five years? If s, describe 04. D yu have unhealed/recurrent injuries r inflamed areas, grwths r sre spts in r arund yur muth? If s, describe where 05. D yu have a prsthetic jint/implant? If s, describe where 06. Have yu had a heart valve replacement r vascular graft? HAVE YOU HAD OR DO YOU CURRENTLY HAVE Rheumatic Fever? 08 Damaged heart valves? 09 Mitral valve prlapse? 10 Heart Murmer 11 High bld pressure? 12 Lw bld pressure? 13 Chest pain / angina? 14 Heart attack(s)? 15 Irregular heart beat? 16 Cardiac pacemaker? 17 Heart surgery? 18 Brnchitis, chrnic cugh? 19 Asthma? 20 Hay fever / sinus prblems? 21 Snring / sleep apnea? 22 Difficulty breathing / lung truble? 23 Tuberculsis? 24 Emphysema? 25 D yu smke? 26 D yu use chewing tbacc? 27 Bld transfusin? 28 Bld disrder such as anemia? 29 Bruise easily? 30 Abnrmal bleeding? 31 Hepatitis, jaundice, r liver disease? 32 Infectius mnnuclesis? HAVE YOU HAD OR DO YOU Yes N NOTES CURRENTLY HAVE... Yes N NOTES 33 Gallbladder truble? 34 Fainting spells? 35 Cnvulsins / epilepsy? 36 Strke? 37 Thyrid truble? 38 Diabetes? 39 Lw bld sugar? 40 Kidney truble? 41 Are yu n dialysis? 42 Swllen ankles, arthritis? 43 Stmach ulcers? 44 Cntagius disease? 45 Sexually transmitted disease? 46 Prblems with the immune system? 47 Delay in healing? 48 A tumr r grwth? 49 Radiatin / chemtherapy? 50 Chrnic fatigue / night sweats? 51 Are yu n a diet? 52 A histry f drug abuse? 53 A histry f alchl abuse? 54 Cntact lenses? 55 Eye disease / glaucma? 56 Mental health prblems? 57 A remvable dental appliance? 58 Pain & clicking f jaws when eating?
3 MEDICATION Are yu nw taking r have taken... Yes N NOTES 59 Any kind f medicatin, drugs, pills? 60 Bld thinners (Cumadin, Plavix, Aspirin, Vitamin E, Gink Bilba)? 61 Have yu ever taken diet pills? 62 Any natural prduct, herbal supplement r hmepathic remedy? 63 Any bne density medicatins / Bisphsphnates (Aredia, Zmeta, Fsamax, Actnel)? 64 Have yu ever taken tranquilizers, sleeping pills, antidepressants, and/r narctics n a regular basis? If s, please list: 65 Please list any medicatins yu are currently taking: ALLERGIES Are yu allergic t, r had a reactin t... Yes N NOTES 66 Lcal Anesthetic (numbing med.)? 67 Penicillin? 68 Other antibitics? 69 Sulfa Drugs? 70 Sdium pentthal, Valium, r ther tranquilizers? 71 Aspirin? 72 Cdeine r ther narctics? 73 Other medicatins? 74 Latex? 75 Sy? 76 Eggs / Ylks? 77 Sulfites? 78 Please list any allergies ther than drug allergies: This Sectin Is Fr Wmen Only. 78 Is there a pssibility f pregnancy? Yes N 79 Expected delivery date 80 Are yu nursing? Yes N 81 Are yu taking birth cntrl pills? Yes N Wmen Nte: Antibitics (such as penicillin) may alter the effectiveness f birth cntrl pills. Cnsult yur physician / gyneclgist fr assistance regarding additinal methds f birth cntrl. IS THIS VISIT RELATED TO AN ACCIDENT? Autmbile yes n Wrk Related yes n Date f Injury Other yes n Insurance Cmpany handling this claim Claim Number Name f Attrney / Adjuster Tel. ( ) IN CASE OF EMERGENCY, CONTACT: Name Hme Tel. ( ) Bus Tel. ( ) FEES AND PAYMENTS We make every effrt t keep dwn the cst r yur ral healthcare. Yu can help by paying with cash, check r credit card at the time f service. Other payment ptins available n a case by case basis including autmatic draft f a checking r savings accunt and pre-payment f dental fees. Please see ur Financial Crdinatr fr details. An estimate f the charges fr any prcedure yu may require will be given t yu upn request. If yu have any dental insurance, we will be glad t fill ut the prper frms, but please cmplete the identifying infrmatin n this frm. Please remember that insurance is cnsidered a methd f reimbursing the patient fr fees paid t the dctr and is nt a substitute fr payment. Sme cmpanies pay fixed allwances fr certain prcedures and thers pay a percentage f the charge. It is yur respnsibility t pay any deductable amunt, c-insurance r any ther balance nt paid fr by yur insurance cmpany. Yu will be respnsible fr all cllectin csts. This signature n file is yur authrizatin fr the release f infrmatin necessary t prcess yur claim.
4 Hunshell Family Dentistry 209-B Pattn Drive Shelby, NC I hereby acknwledge that a cpy f this ffice s Ntice f Privacy Practices has been made available t me. I have been given the pprtunity t ask any questins I may have regarding this Ntice. A Treatment Plan will be presented t yu when treatment is recmmended by the dentist including prpsed treatment, treatment fees and ESTIMATED insurance cverage. If yu have dental insurance, we will be glad t file a claim n yur behalf. Please remember that insurance is cnsidered a methd f reimbursing the patient fr fees paid t the dctr and is nt a substitute fr payment. Sme cmpanies pay fixed allwances fr certain prcedures and thers pay a percentage f the charge. It is yur respnsibility t pay the deductible amunt and c-insurance at the time f service. Yu will be respnsible fr any balance nt paid fr by yur insurance cmpany. Yu will be respnsible fr all cllectin csts. It is yur respnsibility t infrm yur prvider f any insurance r Medicaid changes r terminatins. If yu fail t d s, yu are respnsible fr the balance f services rendered that day. I certify that I have read and understand the statements abve. I have been given the pprtunity t ask questins regarding these statements. I hereby acknwledge authrize the release f infrmatin necessary t prcess a claim t my insurance prvider. Dentistry is nt an exact science and reputable practitiners cannt prperly guarantee results. Despite the mst diligent care and precautin, unanticipated cmplicatins r unintended results, althugh rare, may ccur. A treatment plan is based n the best evidence available during the examinatin. There is n guarantee that this plan will nt change. During treatment, it may be necessary t change r add prcedures because f cnditins that were nt evident during examinatin, but were fund during the curse f treatment. Any change in treatment plan may result in additinal fees. Guarantees and assurances cannt be made by anyne regarding dental treatment. It is essential that yu keep yur appintments and cperate in yur treatment t help insure the best pssible result. I certify that I have read and understand the statements abve. I have been given the pprtunity t ask questins regarding these statements.
5 Hunshell Family Dentistry 209 Pattn Drive, Suite B Shelby, NC Authrizatin fr Release f Infrmatin Name f Patient DOB Hunshell Family Dentistry, Brandn C. Hunshell, DDS PA, is authrized t release prtected health infrmatin abut the abve named patient t the entities named belw. The purpse is t infrm the spuse, parent r thers in keeping with the patient s instructins. Entity t Receive Infrmatin Check each persn/entity that yu apprve t receive infrmatin. Vice Mail: Name Phne Descriptin f Infrmatin t be Released Check each that can be given t persn/entity f the left in the same sectin. Results f Lab Tests/X-rays Other Spuse: Family Billing Infrmatin Financial Medical as Fllws: Parent: (prvide name) Family Billing Infrmatin Financial Medical as Fllws: HOUNSHELL FAMILY DENTISTRY 209-B PATTON DRIVE SHELBY, NC Family Billing Infrmatin Financial Medical as Fllws: Rights f Patient I understand that I have the right t revke this authrizatin at any time and that I have the right t inspect r cpy the prtected health infrmatin t be disclsed as described in the dcument by sending a written ntificatin t Hunshell Family Dentistry, Brandn C. Hunshell, DDS PA. I understand that a revcatin is nt effective in cases where the infrmatin has already been disclsed by Hunshell Family Dentistry, Brandn C. Hunshell, DDS PA, and will be effective ging frward frm the date f revcatin. I understand that infrmatin used r disclsed as a result f this authrizatin may be subject t re-disclsure by the recipient and may n lnger be prtected by federal r state law. I understand that I have the right t refuse t sign this authrizatin and that my treatment will nt be cnditined n signing. This authrizatin shall be in effect until revked in writing by the patient. Signature f Patient r Persnal Representative Date
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:
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:
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
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 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
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
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,
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
Name: Patient relation to Guarantor:
Patient Infrmatin (Please print) Full Legal Name: Last First Middle Date f Birth: SS#: Mnth/Day/Cmplete Year Primary Care Physician: Preferred Name: Sex: Male Female Ethnicity: Hispanic/Latin Nn-Hispanic/Nn-Latin
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
5414 Sunrise Blvd, Ste D Citrus Heights, CA p:
5414 Sunrise Blvd, Ste D Citrus Heights, CA 95610 p: 916.251.9909 Today s Patient information: Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Street Apt. Home
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,
MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print)
Page 1 of 6 Today s date: Patient s Last name: First name: Middle name: Sex: M F MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print) PATIENT INFORMATION Mr. Mrs. Miss Ms. Birth Date: Age:
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
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
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
Dr. Daria Hamrah Patient Information (Facial Cosmetic Procedures and Laser Treatment)
Dr. Daria Hamrah Patient Infrmatin (Facial Csmetic Prcedures and Laser Treatment) PATIENT: New Pt. / Frmer Pt. f Visit First Name M.I. Last Name Sex: M / F f Birth / / Age SS# - - Credit Card*# Exp: Hme
First Name M.I. Last Name. Address City State Zip. Home Tel. ( ) Cell. ( ) . Soc. Sec. # Driver s License #
Date PATIENT INFORMATION Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Date of Birth Age Home Tel. ( ) Cell. ( ) Email Soc. Sec. # Driver s License # Nearest Relative Not Living with You
W ELCOME TO OUR P RACTICE
1.IP Welcome Welcome Welcome W ELCOME TO OUR P RACTICE PATIENT INFORMATION Date Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Se: Male Female Birth Date Age Soc. Sec. # E-mail Street City State Zip
Welcome to our Practice
I= III Welcome to our Practice PATIENT INFORMATION: Mr. Mrs. Ms. Dr. First Name M I Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail_ Today's Street Apt City State._ Zip In case of emergency, please
Dental Insurance Secondary: Insurance PPO HMO (Check one option) Plan Name Phone Address City State Zip Code Employer Union/Local Group # Plan #
PATIENT INFORMATION 813.238.0411 Fax 813.238.5341 801 W. Dr. Martin Luther King Jr. Blvd., Tampa, FL 33603 www.ortaoralsurgery.com Mr. Mrs. Ms. Dr. Name M.I. Last Name Male Female Birthdate Age Social
LAKE AMERICA FAMILY PHYSICIANS
Dr. Amit Aggarwal, M.D FAMILY PHYSICIANS New Patient Registratin Dr. Alka Aggarwal, M.D. First Name: Last Name: Frmer Name (if any): Middle Name: DOB: Gender: M r F SSN: Cntact Infrmatin: Cell Phne #:
PATIENT FORM. Abtin Tabaee, MD. Reviewed By: Referring MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phone: Phone: Phone:
PATIENT FORM Patient Name: Date f Birth: High bld pressure Diabetes Heart disease Strke Asthma Other: Past Medical Histry COPD Thyrid disease Seizures Anxiety Depressin Medicatins (Name, dsage) Referring
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
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
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
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
o Hepatitis o High Cholesterol o High Blood o HIV o IBS o Kidney Disease o Liver Disease
Histry and Physical Name: Height: Weight: She Size: OFFICE USE: BP= / PULSE= List f Current Medicatins: Allergies: Medical Histry: Allergies Anemia Anxiety Arthritis Asthma Back Pain Bld Clts Bleeding
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
o Bad Breath o Grinding Teeth o Sensitivity To Hot
REGISTRATION AND TREATMENT I PATIENT INFORMATION Name Sc. Sec. # LAST FIRST MIDDLE IN. Address E-Mail City State Zip Hme Phne Cell Phne Sex OM OF Age Birth Date Single Married Widwed Child Divrced Patient
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD
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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
PURE WELLNESS CHIROPRACTIC
PURE WELLNESS CHIROPRACTIC PATIENT INFORMATION Date: / / Male: Female: Name: Preferred t be called: Mr. Mrs. Ms. Miss Dr. Birthdate: / / Age: SS#: - - DL#: Hme Address: City: Zip Cde: Single: Married:
PATIENT LIABILITY STATEMENT
PATIENT LIABILITY STATEMENT (Updated 6/17) We will nt initiate therapeutic services until signed authrizatin is prvided. I understand that I am persnally respnsible fr charges incurred fr services rendered
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
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
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
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
You will also discuss with the doctor several anesthesia options for your comfort:
Welcome to Northeast Oral & Maxillofacial Surgery! We appreciate the opportunity to be of service to you. Please complete the enclosed Patient Information and Medical History forms in black or blue ink
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
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Patient Information & Demographics
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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
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT
PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT 1. Patient s Name Last First MI Address Street & Apt # City State Zip Hme Phne Cell Phne Other Phne Any restrictins fr cntacting yu? N
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
Victoria Banuchi Crespo, MD
PATIENT FORM Victria Banuchi Cresp, MD Patient s Name: Date f Birth: Age: Weight: Height: Reasn fr Visit: Occupatin/Emplyer: Marital Status: Name f Spuse/Significant Other: Children s Names & Date f Birth
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:
Georgia Knotek D.D.S. Personalized Dental Care
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Instructin Page Imprtant Nte: Please ntify the financial aid ffice if the student r their parents had a change in marital status after the end f the 2014 tax year n December 31, 2014 and als if the parents
You can get help from government organizations that are not connected with us
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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
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
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:
Today s Date: / / REASON FOR INITIAL VISIT: Whom may we thank for referring you? FIRST MI LAST PREFERRED
Durga Devarakonda, DMD PLLC DD Family Dentistry Family and General Dentistry 972-245-3395 PATIENT INFORMATION PLEASE COMPLETE THE FOLLOWING FORMS TO YOUR FULLEST KNOWLEDGE. DOING SO HELPS US BETTER CARE
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
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
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
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.
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 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
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 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
The Safety Net Foundation
The Safety Net Fundatin Instructins fr Kineret (anakinra) and Sensipar (cinacalcet HCl) Instructins The Safety Net Fundatin prvides temprary prduct assistance t financially needy patients wh meet predetermined
Dry Creek Family Dentistry
Dry Creek Family Dentistry A. Dianne Bustamante, D.D.S. Robert D. Eto, D.D.S. Patient Information PLEASE PRINT NAME PREFERRED ADDRESS CITY STATE ZIP BIRTHDATE HOME PHONE SS# CELL PHONE CIRCLE ONE: minor
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 MEDICAL QUESTIONAIRE
PATIENT FORM William I. Kuhel, MD PATIENT MEDICAL QUESTIONAIRE Name: Ht: Wt: Date: Occupatin: 1. Majr Cmplaint (describe in yur wn wrds why yu are cming in t the see the dctr) 2. Referred by: Name and
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:
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 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.
Welcome to Family Tree Dental Care Midway Rd., Ste 106A Farmers Branch, TX 75244
Patient Information: Patient s Name: Address: City, Zip Code: Email address: Sex: M/F SSN: Date of Birth: Age: Marital Status: Home Phone: Cell Phone: Work Phone: Responsible for Account/Subscriber/Guardian
Address Who referred you to our practice? relationship
Health History Form Date Name Home Phone ( ) Cell ( ) Work ( ) Address City State Zip Code Occupation Height Weight Date of Birth Sex M F SS# Emergency Contact Relationship Phone ( ) E-mail Address Who
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
What do you need? Copy of the HIPAA Policy on Amendment of Protected Health Information
HIPAA Privacy Prcedure #4 Effective Date: April 14, 2003 Reviewed Date: February, 2011 Amendment f Prtected Health Revised Date: February, 2011 Infrmatin Scpe: Radiatin Onclgy ************************************************************************************
New Patient Intake Form
New Patient Intake Frm Patient Infrmatin Rivergate Chirpractic 1994 Gallatin Pike N. Suite 206 Madisn, TN 37115 615-859-6677 Persnal Infrmatin Cntact Infrmatin First Name: Middle Name: Email: (We will
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
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 any questions we ll be glad to help you. We look forward to
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.
375 East Main Street East Islip, NY Welcome!
375 East Main Street East Islip, NY 11730 631-581-5121 www.drforlano.com Welcome! NAME & ADDRESS PATIENT S NAME DATE OF BIRTH WHAT DO YOU PREFER TO BE CALLED? IF PATIENT IS A MINOR, PARENT/GUARDIAN S NAME
Patient Registration Form
Patient Registratin Frm Tday s Date: PATIENT INFORMATION Date f Birth: Sex: M F Hme Address: City: State: Zip: Patient Lives With: MOTHER FATHER BOTH OTHER: We are required t cllect the fllwing infrmatin
NTA LIFE CLAIM PACKET
PROTECTING THE HEART OF OUR COMMUNITY NTA LIFE CLAIM PACKET Included in this packet yu will find: 1. Instructins fr Cmpleting the Health, Accident, and Disability Claim Frm 2. Health, Accident, and Disability
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
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........._
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:
VOLUNTEER REGISTRATION FORM
VOLUNTEER REGISTRATION FORM Office Use Only Prgram: Site: Day(s): Time: Name Email: Phne Number (cell) (hme) (Wrk) Address Birth date What is yur current ccupatin? Are yu r have yu ever been a member f
Belleair Oral Surgery & Implants Ralph M. Eichstaedt, DDS
Belleair Oral Surgery & Implants Ralph M. Eichstaedt, DDS Patient s Information First Name: Last Name: of Birth: Social Security #: Sex: Male Female Marital Status: Single Married Divorced Widowed Separated
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
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
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:
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?
Palm Valley Oral and Maxillofacial Surgery
Palm Valley Oral and Maxillofacial Surgery PATIENT INFORMATION: Male Female Single Married Divorced Widow Minor Name Soc.Sec # Address Apt# City State Zip Home Phone # Work Phone # Cell# Date of Birth
REFERENCE NUMBER: PFS.PDS.115. TITLE: Patient Billing and Collections CURRENT EFFECTIVE DATE: 01/01/2018. PAGE 1 of 8 SCOPE:
PAGE 1 f 8 SCOPE: This Patient Billing and Cllectins Plicy applies t all Presbyterian Healthcare Services (Presbyterian) hspital facilities, including inpatient, utpatient, hme health care services and
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
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
❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
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