Jackson Center Dental

Similar documents
Consent for Treatment

Dental Registration and History

HEALTH HISTORY. Physician s Name Phone# Date of Last Visit

Welcome to CitiDental

Acknowledgement of Receipt of Notice of Privacy Practices

DENTAL REGISTRATION AND HEALTH HISTORY

DENTAL REGISTRATION AND HISTORY

WELCOME TO THE PROVINCES DENTAL CARE

Patient Information. Dental Insurance. Emergency Contact

PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:

PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?

LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas

Michael Mabry, DDS, MAGD

Patient Information. Dental Insurance. Phone Numbers

Patient Information. Your Name: Name you wish to be called: Date: Physical Address: Street Name and Number City Zip Code

Bozart Family Dentistry

WELCOME TO SMILE BY DESIGN

Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n

PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?

Subscriber's Name. Date of Birth. Secondary Insurance Group # ID # DENTAL HISTORY. Yes Yes Yes Yes Yes Yes Yes Yes Yes

Prince Family Dentistry

PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?

Welcome. Name Perferred name Last First MI Mr Mrs Ms Dr Birthdate Social Security Number Single Married Divorced Widowed

Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:

Please print name and Relationship to patient Dental/Medical History Are you having pain or discomfort at this time? Y N Do you feel very nervous abou

Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)

PATIENT REGISTRATION

WELCOME! Patient Information:

Patient Registration

PATIENT REGISTRATION

Patient Information. Patient Name: Preferred Name: Birthdate: SSN: Home Phone: Cell Phone:

Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD

PATIENT REGISTRATION

Candace L. Peterson, DMD

Jeffrey R. Wert, D.M.D., P.C.

PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?

PATIENT REGISTRATION & HEALTH HISTORY FORM

Patient Signature (parent if minor): Date:

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 #

WELCOME PATIENT INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE

PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI

Patient Registration

Patient Information. Health Information

Patient Information. Date: Last First MI

David P. Price, DDS, PA Family Dentistry

Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone

3 Home Work Cell Best time to reach you (Specify someone who does not live in your household.) Name Relationship Home Phone Work/Cell Phone

Primary Insurance Information

PATIENT REGISTRATION

PATIENT REGISTRATION

Patient Information. Date: Last First MI

WELCOME TO LEHIGH DENTAL

Patient Registration

PATIENT INFORMATION BILLING & INSURANCE INFORMATION DENTAL HISTORY

538 SAVANNAH HIGHWAY CHARLESTON, SC (843)

DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS OR CONCERNS? (Circle all correct responses)

Responsible Party (if someone other than the patient)

Patient Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec. # Gender Marital Status Previous Dentist.

New Patient Registration

Dell A. Goodrick, DDS, FAGD

P A T I E N T R E G I S T R A T I O N

Patient Information:

PATIENT REGISTRATION AND HISTORY

GRAND STRAND DENTISTRY B Hwy 544. Conway, SC 29526

Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip

PATIENT REGISTRATION

New Patient Registration

What types of care are you most interested in? Please check all that apply: Cleaning Crowns Implants Braces Dentures Teeth bleaching Pain relief

Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.

Welcomes You! Patient Information. Name: Preferred name: Male Female (Last) (First) (Mi) Home Address: (Street) (City) (State) (Zip)

Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:

Joplin Periodontics & Implant Dentistry Humaira Y. Habib, D.D.S.

Kathryn E. Boehly, DMD & Associates 6290 Linton Boulevard, Building IV, Suite 202, Delray Beach, Florida 33484

Title: Gender: Male Female Family Status: Married Single Child Other Mr/Mrs/Ms/etc. Birth Date: Social Security # Previous Visit Date

DENTISTRY RALEIGH PATIENT INFORMATION INSURANCE INFORMATION IMPLANT & FAMILY. Primary Insurance: (PLEASE PRESENT INSURANCE CARD TO RECEPTIONIST)

Patient Profile. Appointment Preference. Referral Profile. Insurance Profile. First Name Last Name Pref. Name. Date of Birth Age Soc. Sec.

Georgia Knotek D.D.S. Personalized Dental Care

Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone

What to expect at your first visit

Welcome to Metropolitan Dental Care

PATIENT REGISTRATION

Dental History. Medical History

Firewheel Smiles corn

117 FLORAL VALE BLVD, YARDLEY, PA PHONE: FAX: PATIENT INFORMATION

All Dental 76 Otis Street Westborough, MA 01581

PERSONAL HISTORY. Spouse s Name:

PERSONAL INFORMATION

Lasting Impressions Dentistry Sabrina Habib Heppe DDS, PS (206)

WELCOME TO INFINITY DENTAL EXCELLENCE

1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information

WELCOME TO PRAIRIE GARDEN DENTAL. Responsible Party/Primary Insurance Holder If different from above

Responsible Party Information

Patient: Last name: First Name: DOB: Social Security Number: Relationship Status: Sex: F/M

REGISTRATION FORM Section I: Patient Information. Date: Name: SSN: - - Date of Birth:

Insurance Company: Group No.: Insurance address: City:

New Patient Information

New Patient Paperwork

9521 US Hwy 290 West, Suite 103 Austin, TX (512) PATIENT INFORMATION

WELCOME TO OUR PRACTICE

Patient Information. Patient s Name: Preferred Name: Date of Birth: Address: Home Phone: Cell Phone: Work Phone: Marital Status:

Transcription:

Patient Information Jackson Center Dental Insurance Information Date: Social Security#: Patient Last Name: Patient First Name: Address: City: State: Zip Code: Sex: o Male o Female Birthday Date: Age: Married Single Divorced Minor Other Email: Employer/School: Occupation: Employer/School Address: Employer/School Phone: Spouse s Name: Birthday: SS#: Who is responsible for this account? Insurance Company: Subscribers Name: Group Number: SS#: Date of Birth: Is patient covered by additional insurance? Yes No Insurance Company: Subscribers Name: Group Number: SS#: Date of Birth: Assignment and Release I certify that I and/or my dependent(s), have insurance coverage with the company listed herein, and I assign directly to Northwest Dental Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Jackson Center Dental may use my health care information and may disclose such information to my insurance companies named herein and their agents for the purpose of obtaining payment for the services and determining insurance benefits or the benefits payable for related services. Please Print Name Please Sign Name Spouse s Employer: Whom may we thank for referring you? Date Relationship to Patient Phone Numbers: Home/Cell Phone: - - Work Phone: - - Emergency Contact: Name: Relationship: Phone: - - When s the best time to reach you? Dental History: Reason for today s visit: Former Dentist: Date of last dental visit: Date of last dental X-rays: Bad Breathe O Yes O No Jaw Pain O Yes O No Sensitivity to sweets O Yes O No Bleeding Gums O Yes O No Lip/cheek biting O Yes O No Sensitivity to biting O Yes O No Blisters on lips or mouth O Yes O No Loose teeth O Yes O No Smoking Cigarette/Pipe O Yes O No Burning sensation on tongue O Yes O No Mouth Breathing O Yes O No Sores in your mouth O Yes O No Chew on one side O Yes O No Mouth Pain O Yes O No How often do you floss? Clicking or popping jaw O Yes O No Ortho Treatment /Braces O Yes O No Dry mouth O Yes O No Pain around Ear O Yes O No Fingernail biting O Yes O No Periodontal/Gum Treatment O Yes O No How often do you brush? Food collection b/t teeth O Yes O No Sensitivity to cold O Yes O No Grinding teeth O Yes O No Sensitivity to heat O Yes O No

Health History Family Physician s Name: Date of last visit: Have you ever used a bisphosphonate medication? O Yes O No (Common brand names are Fosamax, Actonel, Atelvia, Didronel or Boniva) Have you ever taken any of the group drugs collectively referred to as fen-phen? These include combinations of Ionimin, Adipex, Fastin (brad names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). O Yes O No Please mark X if you have any of the following conditions: AIDS/HIV O Yes O No Epilepsy O Yes O No Rheumatic Fever O Yes O No Anemia O Yes O No Fainting O Yes O No Scarlet Fever O Yes O No Arthritis O Yes O No Glaucoma O Yes O No Shortness Of Breath O Yes O No Artificial Heart Valves O Yes O No Heart Murmur O Yes O No Sinus Trouble O Yes O No Artificial Joints O Yes O No Heart Problems O Yes O No Skin Rash O Yes O No Asthma O Yes O No Hepatitis Type O Yes O No Special Diet O Yes O No Autism O Yes O No Herpes O Yes O No Stroke O Yes O No Back Problems O Yes O No High Blood Pressure O Yes O No Swollen Feet/Ankles O Yes O No Bleeding abnormally O Yes O No Jaundice O Yes O No Swollen Neck Glands O Yes O No Blood Disease O Yes O No Jaw Pain O Yes O No Thyroid Problems O Yes O No Cancer O Yes O No Kidney Disease O Yes O No Tonsillitis O Yes O No Chemical Dependency O Yes O No Liver Pain O Yes O No Tuberculosis O Yes O No Chemotherapy O Yes O No Low Blood Pressure O Yes O No Tumor or Growth O Yes O No Circulatory Problems O Yes O No Mitral Valve Prolapse O Yes O No Ulcer O Yes O No Congenital Health Lesions O Yes O No Alzheimer s/dementia O Yes O No Venereal Disease O Yes O No Cortisone Treatments O Yes O No Nervous Problems O Yes O No Weight Loss O Yes O No Cough, persistent/bloody O Yes O No Pacemaker O Yes O No Are you pregnant? O Yes O No Diabetes O Yes O No Psychiatric Care/Mental Illness O Yes O No Taking birth control pills? O Yes O No Emphysema O Yes O No Radiation Treatment O Yes O No Are you nursing? O Yes O No Medications List or supply a copy of any medications you are currently taking: Pharmacy Name: Allergies O Aspirin O Barbiturates (sleeping pills) O Codeine O Iodine O Latex O Local Anesthetic O Penicillin O Sulfa O Other:

General Consent Form I hereby agree on this date Print Patients Full Name Today s Date to allow the doctors and staff of Jackson Center Dental to treat me for any and all necessary dental concerns that may be present now or in the future, including but not limited to: periodontal treatment (gums), prophylaxis (cleaning & exam), restorative dentistry (fillings), endodontics (root canals & pulp treatments), prosthodontics (dentures & partials), sealants (coatings on teeth), bleaching (whitening), bonding & veneers (cosmetic dentistry), Invisalign (clear braces), Nitrous Oxide (laughing gas), local anesthetic (lidocaine injection), exodontia (tooth extraction), TMJ/TMD dysfunction (jaw joint pain), radiographs (x-rays) and other general dental care. I realize I will have the opportunity to decline treatment at any time. I have read the statement above and hereby consent to treatment when and if the doctors or staff inform me that it is needed, by signing this form below. In addition, I understand that by keeping the appointment scheduled for any procedure listed or unlisted that I am giving my consent for treatment. Patients Signature Today s Date If the patient is a child or young adult under the age of 18 please sign below. Parents Signature or Guardian Today s Date

Our Commitment Financial Policy Jackson Center Dental is committed to the highest quality dental care possible, offering affordable services with maximum payment flexibility. Before treatment is undertaken we will consult with you so that you fully understand the need, the procedures, and the expense of your dental treatment. Together, we will implement the best plan for your dental care. In order to achieve this, we need your understanding of our payment policy. Payment Options Payment is due at the time services are rendered unless other arrangements have been made in advance. In all cases, payment in full is required at treatment completion. For your convenience, we offer the following options: 5% Cash or Check Discount Patients who pay their entire bill by cash or check at the time services are rendered (whether they have dental insurance or not) will receive a 5% reward. We will assist patients with dental insurance by filing their claim and we will instruct the insurance company to reimburse the patient directly. VISA, Master Card, Discover or American Express Dental Insurance It is important to understand our relationship is with you, not your insurance company. Additionally, our fees are the same for all patients regardless of their insurance coverage. We will present a treatment plan and an estimate of expenses, if needed, after the patient examination. Estimates are based upon available insurance information and do not guarantee payment by your insurance company. We will bill your insurance company as a courtesy; however, co-payments and deductibles are due at the time of service. Patients with dual insurance should know that they are not guaranteed 100% coverage. Fees not covered by insurance are the patient s responsibility. Care credit Financing Option Care credit is a nationally recognized credit provider that specializes in assisting individuals with financing for their dental care. Care credit provides patients with interest free payment plans as well as extended payment plans for patients who prefer more time to pay. Patients may be approved for Care credit within a couple of minutes at our office. More information about using Care credit may be obtained from the Jackson Center Dental staff. In all cases, approval for Care credit should be arranged prior to treatment Senior Reward We are pleased to extend a 5% discount to our senior patients (62 years and older) regardless of payment method. Please note that this cannot be combined with the cash discount. New Patient Emergency Appointments We request payment at the time of service for new patient emergency procedures. We will accept cash, personal checks and money orders for new patient emergency appointments. Broken Appointment Policy We anticipate that all patients will keep their scheduled appointments and we will make a reasonable effort to help them do so. However, situations do arise which may cause a patient to reschedule. We will gladly reschedule appointments, but we require 24 hours advance notice. Patients who fail to attend their appointments and have not provided us with 24 hours advance notice will be charged a $50 broken appointment fee. In addition, patients who arrive late for their scheduled appointment time may have to forfeit their appointment and may be subject to the broken appointment fee. Acceptance of Terms I have read and fully understand the above financial policies and agree to the terms outlined herein. Date (Signature of Patient or Guardian) Signature of Patient

Acknowledgement of Receipt of Notice of Privacy Practices * You May Refuse to Sign This Acknowledgment* I have received a copy of this office s Notice of Privacy Practices. Print Name: Signature: Date: For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations. 2010, 2013 American Dental Association. All Rights Reserved.

Agreement to received electronic communications Patient Name: Date of Birth: I agree that the dental practice may communicate with me electronically at the email address below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address. I can withdraw my consent to electronic communications by calling: [419-222-4342]. Email Address (PLEASE PRINT CLEARLY): @. Patient Signature: Date:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback