To the new members of our practice,
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- Justina Bridges
- 6 years ago
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1 To the new members of our practice, John J. Denison, DDS PC 895 City Center Blvd #106 Newport News, VA drdenison.com Dr. John J. Denison and his staff want to thank you for making the decision to join our practice. We are very glad to have you as members of our dental family, and we want you to know that we take great pride in providing you with the best possible dental care. We will provide you with state of the art dental care and a comfortable, relaxing environment. We are a comprehensive dental practice, which means that we provide all your treatments here, whenever possible. You will be provided with detailed examinations that not only inform you about your dental health, but also how your dental health impacts your total physical health. Your examination will include a thorough head and neck examination, cancer screening examination, evaluation of your gums and teeth, radiographs and photographic evaluation of your oral condition. You will be given direction in brushing and flossing techniques, and you will be provided with a detailed report of any findings. If you have dental insurance, the report will include an estimation of the insurance assistance. Dr. Denison also offers cosmetic dental treatments that can enhance an already beautiful smile, or completely restore a neglected mouth to perfection. Dr. Denison performs crown and bridges as well as implants. Dr. Denison realizes that a persons self-confidence, as well as opportunities for advancement, are greatly affected by appearance. He will be happy to talk to you about any of these treatments. Again, welcome to our practice. We look forward to serving all your dental needs. If you ever have any questions about your treatment, or you have any recommendations as to how we can better serve you, do not hesitate to speak to Dr. Denison or any member of his staff. Thank you!
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4 895 Middle Ground Blvd., Suite 106 John J. Denison, D.D.S., P.C. A Division of Atlantic Dental Care, PLC Family & Cosmetic Dentistry Family Oyster & Point Cosmetic Professional Dentistry Park Middle City Center Ground Blvd., Suite Suite Newport News, VA The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out these forms completely. The better we communicate, the better we can care for you. Thank you. First Name Last Name Middle In Nick Name Salutation Check all that apply: Patient Policy Holder Responsible Pary Party Address City State Zip Home Cell Employer Ext Sex: Male Female Status: Married Single Minor (under 18 years old) Birthdate / / Social Security # Driver License # Can we you? Yes No Can we text you? Yes No Who may we thank for referring you? Person to notify in the case of an emergency Relationship Work# Home# Responsible Party Address Home Work City State Zip Employer Birthdate / /19 Social Security # If you have given us a Post Office Box for your mailing address, please provide your actual physical address: Street City State -over please-
5 Insurance Information and Authorization Primary Insurance Coverage: Name of Insured Relationship to Patient Insured s Birth date / /19 Social Security # Employer/School Name of Insurance Company Group#/Name Id# Deductible Amount Max Annual Benefit Secondary Insurance Coverage: Name of Insured Relationship to Patient Insured s Birthdate / /19 Social Security# Employer/School Name of Insurance Company Group#/Name Id# Deductible Amount Max Annual Benefit Please Read and Sign: The payment for services is due on the day services are rendered, unless other means of payment are agreed upon by the undersigned and the office of John J Denison, D.D.S., P.C. I authorize the filing of claims against any insurance in force, and further assign and direct payment to John J Denison, D.D.S., Pc.C. The undersigned understand that he/she is responsible for payment of any charges not covered by this assignment, and that any monies recovered in excess of the patient s indebtedness will be refunded. In the event of default on any payment due I agree to pay all costs of collection as well as any attorney fees and court costs deemed reasonable by the court. I authorize my dental treatment and release of any medical or dental information to process claims for services rendered. Signature Signature of patient over 18 years of age or parent or legal guardian Date
Patient Dental History
Justin M. Russo, DDS, PLLC What is the main reason for your visit today? Other/Comments: Patient Dental History Cleaning Tooth Pain Sensitivity Whitening Fresher Breath Implants Dentures When was your
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First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
Patient Registration
Patient Registration First Name: Middle Initial: Last Name: Address: City: State / Zip: Responsible Party (for patients under 18): Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security Number:
Personal Information. Date of Birth: / / SSN: - - Single Married Child Other. Home Address: Street City State Zip
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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.
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.
If you are already an established patient of either Dr. Aroesty or Ms. Corrice, you do not have to reregister or fill out any additional paperwork.
To Our New Patient: Our staff would like to take this opportunity to welcome you to Garden State Snoring Solutions, LLC. It is our goal to make your visit with us as pleasant and comfortable as possible.
What types of care are you most interested in? Please check all that apply: Cleaning Crowns Implants Braces Dentures Teeth bleaching Pain relief
Client Information Name Preferred Name Address Birthdate City, Zip Code S.S.N Home Phone Work Phone Cell Employer Occupation Location May we contact you at work? Yes No When is the best time to contact
NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK
PATIENT INFORMATION NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - ADDRESS CITY STATE ZIP HOME PHONE CELL OTHER EMAIL How did you hear about our office? HEAD OF HOUSEHOLD NAME: LAST FIRST MI