Sunny Smiles Pediatric Dentistry
|
|
|
- Andrea Washington
- 5 years ago
- Views:
Transcription
1 Sunny Smiles Pediatric Dentistry Patient: Tday s Date: Nickname/Preferred Name: Date f Birth: Age: Sex: M F Schl: Grade: Hme Address: City: Zip: Phne Number: Scial Security Number: Wh has legal custdy f this patient? Hw did yu hear abut ur ffice? Reasn fr tday s visit: MOTHER S INFORMATION: Name: Date f Birth: Emplyer: Scial Security Number: Wrk Phne #: Hme Phne #: Cell Phne #: FATHER S INFORMATION: Name: Date f Birth: Emplyer: Scial Security Number: Wrk Phne #: Hme Phne #: Cell Phne #: PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT: Name: Relatinship t Patient: Billing Address: City: Zip: Wrk Phne #: Hme Phne #: Cell Phne #: E mail address: INSURANCE INFORMATION Dental Insurance Cmpany: Grup #: Phne #: Name f Insured:
2 Physician s Name: Phne #: Date f last physical: Please list any knwn allergies: Please list all current medicatins this patient is taking, including the reasn fr taking the medicatin: Des yur child need pre medicatin with antibitics befre dental appintments? Has yur child ever been hspitalized? If yes, please describe when and why: Has yur child ever been treated in the emergency rm? If yes, please describe when and why: Has yur child ever had surgery? If yes, please describe when and why: Has yur child ever been diagnsed with r treated fr the fllwing? ADHD/Hyperactivity Breathing Prblems Heart Murmur Premature Birth Allergies Cancer/Tumr Hepatitis Rheumatic Fever Anaphylactic Shck Cerebral Palsy High Bld Pressure Seizures/Epilepsy Anemia Cleft Lip/Palate HIV/AIDS Sleep Apnea Arthritis Delayed Speech Kidney Disease Sickle Cell Disease Artificial Jints Develpmental Delay Latex Sensitivity Sinus Prblems Asthma Diabetes Liver Disease STD Birth Defects Fainting Spells Lw Birth Weight Tnsillectmy Bladder Disease Head/Neck Injury Mental/Nervus Disrder Tuberculsis Bleeding Prblems Hearing Impairment Pacemaker Visin Prblems Bld Disrder Heart Cnditin Pregnancy Other If ther, please specify: Please elabrate n any f the abve marked yes: When was yur child s last dental visit? Previus dentist s name and address: Why did yur child leave his/her previus dentist? When were X rays last taken f yur child s teeth? D yu have any cncerns regarding his/her teeth? Des yur child clench r grind his/her teeth? Des yur child have any tth, jaw, r muscle discmfrt? Des yur child have frequent headaches? Des yur child have a click, pp, r ther nise in the jaw jint? Are yur child s teeth sensitive t ht r cld? Are any f yur child s teeth uncmfrtable fr him/her when he/she bites? D yur child s gums bleed when brushing r flssing?
3 Des yur child have any cncerns abut the appearance f his/her teeth? Des yur child have a histry f an accident r injury invlving the teeth/jaws? Des yur child get cld sres r canker sres? Des yur child have a habit f snring r muth breathing? Des yur child have a current r previus habit invlving a pacifier r thumb/finger sucking? Des yur child have a histry f ging t sleep with a baby bttle r n demand breast feeding? Des yur child frequently eat sweets and/r drink juices r sdas? Des yur child nly drink bttled, highly filtered, r well water? D yu supervise r assist yur child in brushing his/her teeth? Des yur child use tthpaste with fluride? Des yur child use fluride tablets r rinses? Des yur child use dental flss? Hw has yur child reacted t previus medical r dental prcedures? Hw d yu expect yur child t react in the dental chair? What are yur child s interests and hbbies? Please list any cnditins r cncerns regarding yur child s health that have nt been cvered in this questinnaire: I, the undersigned parent/legal guardian f this child, certify that the abve is accurate and cmplete t the best f my knwledge. I will ntify the dentist and/r the staff f any change in the abve prir t any appintment. Signature: Name: Date: Relatinship t Patient: I, the undersigned parent/legal guardian, hereby give cnsent fr the dentist and/r clinical staff t examine this child, clean his/her teeth, perfrm all necessary dental treatment, administer lcal anesthetics, administer medicatins, apply tpical fluride, take diagnstic radigraphs (X rays), take clinical phtgraphs, btain study mdels and ther recrds necessary fr an accurate diagnsis fr my child. I understand that dental treatment fr children invlves behavir guidance, which may include the use f praise, explanatin and demnstratin f prcedures and instruments, variable vice tne, muth prps, nitrus xide (laughing gas), r prtective stabilizatin when necessary t prmte cperative behavir and a psitive experience and t prtect my child frm ptential injury. Signature: Name: Date: Relatinship t Patient:
4 Sunny Smiles Pediatric Dentistry 8525 Dr.MLK Jr. St. Nrth St. Petersburg, FL (727) CANCELLATION / MISSED APPOINTMENT POLICY Our ffice strives t prvide ptimum treatment and cnvenience fr ur patients by ffering accmmdating and flexible scheduling. Therefre, we ask that yu help us by keeping yur scheduled appintments, and by ntifying ur ffice in advance if yu are unable t d s. We have a waiting list fr appintments and when given advance ntice we are ften able t accmmdate ther patients. ALL PATIENTS WHO FAIL TO ARRIVE FOR THEIR SCHEDULED APPOINTMENTS OR WHO CANCEL WITH LESS THAN 24 HOURS ADVANCE NOTICE WILL BE CHARGED A MISSED APPOINTMENT FEE Missed appintment fees are NOT cvered by insurance plans and are yur respnsibility t pay If yu need t cancel r reschedule an appintment, please give at least 24 hurs ntice t avid a charge If yu fail yur appintment and have nt ntified the ffice 24 hurs in advance yu will be charged a missed appintment fee If yu miss tw cnsecutive appintments, any remaining appintments scheduled will be cancelled and referring dentist will be ntified. Thank yu fr yur cperatin. Patient Name (please print): Signature belw indicates I have read and understand this plicy. Patient(18 r lder) r Legal Guardian Signature:
5 Sunny Smiles Pediatric Dental Office 8525 Dr. MLK Jr. St. Nrth St. Petersburg, FL (727) INSURANCE BENEFIT ACKNOWLEDGEMENT Having insurance is nt a substitute fr payment. Many cmpanies have fixed allwances r percentages based n the cntract yu have with them, nt with ur ffice. It is yur respnsibility t pay deductible, cinsurance, and any ther balances nt paid by yur insurance cmpany. In determining the amunt f benefits payable, yur insurance cmpany may give cnsideratin t an alternate prcedure that may accmplish a prfessinal satisfactry result. If an alternate benefit prvisin is applied t a prcedure perfrmed by yur dentist and submitted t yur insurance cmpany as a claim, the amunt f mney yu we yur dentist may be mre than the amunt specified n the Explanatin f Benefits (EOB). Estimates f cverage are nt a guarantee as eligibility, plicy prvisins and pssible charges frm ther ffices affect payment. Yur insurance cmpany may nt pay their full estimated prtin. YOU ARE RESPONSIBLE FOR ALL TREATMENT CHARGES NOT PAID BY YOUR INSURANCE COMPANY. I agree t pay the fees, including any deductible, c insurance, and any ther balances nt paid by my insurance cmpany, t Dental Specialty Grup f Pinellas. Signature f Patient/ Legal Guardian if patient is minr Date Patient s Name
6 Sunny Smiles Pediatric Dentistry Acknwledgement f Receipt f Ntice f Privacy Practices Purpse: This frm is used t btain acknwledgement f receipt f ur Ntice f Privacy Practices r t dcument ur gd faith effrt t btain that acknwledgement. **Yu May Refuse t Sign This Acknwledgement** I have been given cpy f this ffice s Ntice f Privacy Practices t review and I am aware that the ffice has a cpy f the Ntice available t take with me if I request ne. {Please Print Patient s Name} {Signature f Patient r Legal Guardian} {Date} Sunny Smiles Pediatric Dentistry may use r disclse prtected health infrmatin fr the purpse(s) f treatment, payment, cllectins, r health care peratins. We may disclse yur persnal health care infrmatin t ther dental and/r medical prfessinals relating t yur treatment, payment, r health care. If yu wish t authrize Sunny Smiles Pediatric Dentistry t release yur persnal health care infrmatin t anyne ther than fr the reasns abve, please list belw Fr Office Use Only We attempted t btain written prf f Infrmed Acknwledgement f Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify) 2002 American Dental Assciatin All Rights Reserved Reprductin and use f this frm by dentists and their staff is permitted. Any ther use, duplicatin r distributin f this frm by any ther party requires the prir written apprval f the American Dental Assciatin. This Frm is educatinal nly, des nt cnstitute legal advice, and cvers nly federal, nt state, law (August 14, 2002).
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
Medical History. Yes or No
Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
Screening Questions to Ask Patients
Screening Questins t Ask Patients 1. Have yu ever had TB (Tuberculsis)? Yes N 2. Have yu been living with anyne in the past tw years that has been diagnsed with TB? Yes N 3. Have yu ever had a Persistent
Street Address: City: State: Zip: Home Ph: Cell Ph: SSN#: Name: Relationship to Patient: Address: City: State: Zip: Home Ph: Cell Ph:
PATIENT INFORMATION Name: Birthdate: Street Address: City: State: Zip: Hme Ph: Cell Ph: Email: SSN#: Sex (circle) M F Emplyer Name & Phne #: PARENT/GUARDIAN INFORMATION (IF UNDER THE AGE OF 18) Name: Relatinship
Patient Name Date of Birth. Address. City State Zip. Cell Phone Work Phone Home Phone . SSN Employer Name Employer Number.
Waldrf Peridntics & Implants Amal Rastgi, DMD, MSD, PhD Cary Bly, DDS, MSD Bard Certified Specialists in Peridntlgy 11855 Hlly Lane #106 Waldrf, MD 20601 301-645-3100 (F) 301-885-0600 waldrfperidntics@yah.cm
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
Idaho Naturopathic Medicine 6550 W Emerald, Ste 112 Boise, Idaho Ph: Fax:
Idah Naturpathic Medicine 6550 W Emerald, Ste 112 Bise, Idah 83704 Ph: 208-275- 0007 Fax: 208-323-9909 www.idahnaturpathicmedicine.cm Welcme t Idah Naturpathic Medicine We lk frward t meeting yu sn. It
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
Dental Benefits. Under the TeamstersCare Plan, you and your eligible dependents have three basic options when you need dental care.
Dental Benefits Under the TeamstersCare Plan, yu and yur eligible dependents have three basic ptins when yu need dental care. Optin #1: TeamstersCare Dentists. Yu can use ur in-huse Charlestwn, Chelmsfrd,
Myrtle Grove Chiropractic & Acupuncture Center
FOR OFFICE USE ONLY Myrtle Grve Chirpractic & Acupuncture Center C BC/BS MC MD AA O WELCOME TO YOUR HEALTH HAPPINESS & HOPE CLINIC TODAY S DATE: PURPOSE OF APPOINTMENT: CONSULTATION TREATMENT OTHER HOW
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please circle): Male Female Age: Date
OFFICE POLICY AGREEMENT
OFFICE POLICY AGREEMENT MINOR CONSENT FORM, If applicable: Cnsent t receive dental treatment: I hereby cnsent and authrize the dctrs and staff members t examine, clean and prvide dental treatment t my
FOLLOW-UP IN-DEPTH INTERVIEW GUIDELINES
Appendix h STUDY NUMBER: COST OF UNSAFE ABORTION FOLLOW-UP IN-DEPTH INTERVIEW GUIDELINES T be administered abut 2-3 weeks after leaving the health facility 1. IDENTIFICATION 101. Patient identificatin
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
CONSENT FOR KYBELLA INJECTABLE FAT REDUCTION
CONSENT FOR KYBELLA INJECTABLE FAT REDUCTION INSTRUCTIONS This is an infrmed cnsent dcument which has been prepared t help yur Dctr infrm yu cncerning fat reductin with an injectable medicatin, its risks,
Tell Us About Your Child
5C Medical Park Drive Pomona, NY 10970 (845) 414-9626 drsmith@smithslittlesmiles.com www.smithslittlesmiles.com Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and
For our protection, we require verification that you have received this notice. Therefore, please sign below.
PATIENT INFORMATION Dear Patient: Sleep prblems are extremely cmmn. Public health and safety are threatened by the increasing prevalence f bstructive sleep apnea, which nw afflicts at least 25 millin adults
Address (if different from above):
Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
Scott J. Owens, D.D.S. Marc L. Dwoskin, D.D.S., P.C. processed by us for your convenience. We offer prompt care for all emergencies.
Welcme t A very warm welcme t yu! The entire team wuld like t thank yu fr selecting ur ffice t care fr yur dental needs. We are a family-riented dental practice lcated n the suthwest crner f Furteen Mile
EAST VALLEY DERMATOLOGY CENTER
EAST VALLEY DERMATOLOGY CENTER Adult and Pediatric Dermatlgy VALLEY SKIN CANCER SURGERY PATIENT INFORMATION RECORD Please Use Black Ink Only Patient Infrmatin Patient s Name Last First Middle Initial Address
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
Home Address: Home Telephone: CHILD 1 First Name: Last Name: School: Age: Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION PATIENT INFORMATION Birthday: / / Sex:
Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: E-mail: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What
Welcome to Renew Family Dentistry Joshua F. Maxwell DDS, FAGD, FICOI, PC 5575 Warren Parkway Suite 324 Frisco, Texas Office:
Welcme t Renew Family Dentistry Jshua F. Maxwell DDS, FAGD, FICOI, PC 5575 Warren Parkway Suite 324 Frisc, Texas 75034 Office: 469-633 633-0550 Fax: 214-705 705-0529 0529 www.renewdentistry.cm smile@renewdentistry.cm
For our protection, we require verification that you have received this notice. Therefore, please sign below.
PATIENT INFORMATION Dear Patient: Sleep prblems are extremely cmmn. Public health and safety are threatened by the increasing prevalence f bstructive sleep apnea, which nw afflicts at least 25 millin adults
List the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. Yvette E. Thompson, D.D.S. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please
Colon Hydrotherapy Prep
Cln Hydrtherapy Prep PROCEDURE DATE: COLON CLEANSE APPOINTMENT TIME: ***After yu finish with yur cln cleanse yu will g directly t Summit Endscpy Center (Suite C) *** IF YOU HAVE A BOWEL MOVEMENT 3 OR LESS
Artemis Physical Therapy Patient Information
Artemis Physical Therapy Patient Infrmatin Client Infrmatin Last Name First Name MI Address City Zip Date f Birth Female Male Emplyer (ptinal) Cntact Infrmatin Hme Phne Cell Phne Wrk Phne (ptinal) Email
Health for Life Chiropractic At Cloverdale Mall Unit # The East Mall Etobicoke, ON, M9B 3Y
Health fr Life Chirpractic At Clverdale Mall Unit #143-250 The East Mall Etbicke, ON, M9B 3Y8 416-232-1822 416-232-0060 Child and Adlescent Health Questinnaire Name:_ Birth date: Address:_ Telephne: Medical
Patient Name: Date: Address City/State Zip Code. Home. Phone Cell: Work.
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by:
Bariatric Surgery FAQs for Employees in the GRMC Group Health Plan
Bariatric Surgery FAQs fr Emplyees in the GRMC Grup Health Plan Gergia Regents Medical Center and Gergia Regents Medical Assciates emplyees and eligible dependents wh are in the GRMC Grup Health Plan (Select
GUIDANCE DOCUMENT FOR ENROLLING SUBJECTS WHO DO NOT SPEAK ENGLISH
GUIDANCE DOCUMENT FOR ENROLLING SUBJECTS WHO DO NOT SPEAK ENGLISH Aurra Health Care s Research Subject Prtectin Prgram (RSPP) This guidance dcument will utline the prper prcedures fr btaining and dcumenting
VIRGINIA OBSTETRICS & GYNECOLOGY, P.C.
VIRGINIA OBSTETRICS & GYNECOLOGY, P.C. 19490 Sandridge Way Suite 350 Leesburg, VA 20176 Phne (703) 858-5599 Fax (703) 858-5699 PERSONAL INFORMATION: PATIENT INFORMATION SHEET Please Print Date. Patient's
Pediatric Health History Form
Pediatric Health Histry Frm Child s Name Date f Birth Mther s Name Father s Name Parent Cncerns - Please explain any ther cncerns r questins yu have abut yur child Des yur child have any allergies? Yes
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Limitations and Exclusions (What is Not Covered)
Clrad Dental Family + Pediatric Plan Exclusins and Limitatins Limitatins and Exclusins (What is Nt Cvered) Excluded Services: Age 19 and lder Cvered Expenses d nt include expenses incurred fr: prcedures
Thank you for visiting Main Street Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Thank yu fr visiting Main Street Dental Care. We want yur visit t be pleasant and cmfrtable. Please help us by cmpleting this frm. Patient Infrmatin Name LAST FIRST MIDDLE INITIAL NICKNAME Address STREET
PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
PATIENT INFORMATION Date Last Name: First Name: Address: City/State/Zip: Phne: (H): (W): (C): Email: Date f Birth: Gender: Male Female EMERGENCY CONTACT INFORMATION Last Name First Name Middle Initial
PROCEDURAL SAFEGUARDS NOTICE PARENTAL RIGHTS FOR PRIVATE SCHOOL SPECIAL EDUCATION STUDENTS
PROCEDURAL SAFEGUARDS NOTICE PARENTAL RIGHTS FOR PRIVATE SCHOOL SPECIAL EDUCATION STUDENTS INTRODUCTION This ntice prvides an verview f the parental special educatin rights, smetimes called prcedural safeguards
New Patient Information
New Patient Information Bloomfield Children s Dentistry 6405 Telegraph Road Bloomfield Hills, MI 48301 In order to get to know your family better, and to provide you with the best service, we ask that
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
Iowa Early Periodic Screening, Diagnosis and Treatment Care for Kids Program Provider Training
Iwa Early Peridic Screening, Diagnsis and Treatment Care fr Kids Prgram Prvider Training The Early Peridic Screening, Diagnsis and Treatment (EPSDT) Care fr Kids prgram is Iwa s Medicaid prgram fr children.
Fee Schedule - Home Health Care- 2015
Fee Schedule - Hme Health Care- 2015 01/01/2015 1600 E Century Ave Ste 1 PO Bx 5585 Bismarck ND 58506-5585 www.wrkfrcesafety.cm Cpyright Ntice The five character cdes included in the Nrth Dakta Fee Schedule
Health Screening Record: Entry Level Due: August 1st MWF 150 Entry Year
Health Screening Recrd: Entry Level MIDWIFERY EDUCATION PROGRAM HEALTH SCREENING REQUIREMENTS (Rev. June 2017) 1. Hepatitis B: Primary vaccinatin series (3 vaccines 0, 1 and 6 mnths apart), plus serlgic
Colorado Essential Health Benefit for Children
Smile fr Kids LOW EHB This summary f benefits, alng with the exclusins and limitatins describe the benefits f the Essential Health Benefit (EHB) fr Children. Please review clsely t understand all benefits,
Child s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:
Welcome Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their
Patient Information Packet Date:
Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email:
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Patient s Full Name Age Sex: (M) (F) Whom may we thank for referring you?
Date: / / Patient Information Patient s Full Name Age Sex: (M) (F) Nickname (if any) Birthdate: / / Whom may we thank for referring you? General Information Parent/Legal Guardian (full name) Birthdate:
Who is responsible for this account Relationship to patient. How did you hear about us (referral, facebook, etc.)?
EMERGENCY CONTACT INSURANCE PATIENT INFORMATION Name of Minor/Child SSN Sex: M F Age Birthdate Nickname Mailing Address City, State, Zip Physical Address City, State, Zip Home Phone Work Cell Email Address
MEDICAL /HISTORY REGISTRATION FORM **PLEASE PRINT** Insurance Information (If this is cosmetic, please disregard this section)
Date: Sex M F **PLEASE PRINT** Insurance Infrmatin (If this is csmetic, please disregard this sectin) Patient Name: Address: City: State: Zip: SS#: Hme Ph: Cell: Are yu emplyed? Self Emplyed Retired Name
NEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Email Address Fr cnfirming appintments, wuld yu prefer? EMAIL r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single
Trillium and Willamette Dental Group: Dental-Medical Diabetes Management and Care Coordination
Trillium and Willamette Dental Grup: Dental-Medical Diabetes Management and Care Crdinatin Grant Prpsal Willamette Dental Grup (WDG) was awarded $117,024 as part f Trillium s Transfrmatin Grant Prgram:
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
Get Acquainted Questionnaire Tell Us About Your Child!
Get Acquainted Questionnaire Tell Us About Your Child! Today s Date Child s First Name Child s Last Name Nickname M F Child s Age Child s Date of Birth / / Residence Address City State Zip Residence Phone
NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY
NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY Date: Patient Information Child s Full Name Age Sex (M) (F) Nickname (if any) Birth Date Whom may we thank for referring you General Information Mother/ Father
Welcome to Skyline Pediatric Dentistry!
Welcome to Skyline Pediatric Dentistry! Patient Information Patient Name: Preferred Name: Today s Date: Birth Date: Age: Social Security #: Male Female Names of siblings: Responsible Party Information
Patient Information. Name Date of Birth Age. Address. (Street Apt City State Zip) Social Security Number - - Home Phone - - Marital Status
Patient Infrmatin Name Date f Birth Age (First Middle Last) Address (Street Apt City State Zip) Scial Security Number - - Hme Phne - - Marital Status Male Female Cell Phne - - Name f Spuse r Parent (if
Welcome to Dr Jamie Italiane-DeCubellis s office
Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality
Appendix C SCHEDULE OF BENEFITS FOR THE LOW COST MEDICAL PLAN OF BENEFITS
Appendix C SCHEDULE OF BENEFITS FOR THE LOW COST MEDICAL PLAN OF BENEFITS The schedule n the fllwing pages highlights key features f the Lw Cst Medical Plan f Benefits fr Cvered Individuals. These benefits
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive 256-766-0270 Father: DOB: SS#: Home Address: Home #: Work #: Cell #: Employed By: Address: Do you have dental insurance? Yes No
2016 CWA Political Action Fund Administrative Procedures Checklist
2016 CWA Plitical Actin Fund Administrative Prcedures Checklist 1. Dates f Prgram The 2016 CWA Plitical Actin Fund (federal plitical actin cmmittee- CWA-COPE PCC) Prgram will be cnducted n a calendar year
Kids Dental Care Adult Patient Registration
Kids Dental Care Adult Patient Registration To be updated every two years Patient's Name: DOB: SS# Sex: Male / Female Address: Apt/Unit/Floor: City: State: Zip Code: Home Phone #: ( ) - Cell Phone #: (
Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:
Patient s Last Name: First Name: Address: City: State Zip Phne: (Hme) (Wrk): (Cell): Age f Birth / / Email: Occupatin Referred by: Patient s cnditin: Duratin f Prblem: Dctr: Dctr s Telephne: N. in husehld
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
Imaging tests allow the cancer care team to check for cancer and other problems inside the body.
IMAGING TESTS This infrmatin may help answer sme f yur questins and help yu think f ther questins that yu may want t ask yur cancer care team; it is nt intended t replace advice r discussin between yu
Neighborhood Chiropractic and Acupuncture LLC Registration and History
PATIENT INFORMATION Neighbrhd Chirpractic and Acupuncture LLC Registratin and Histry Last Name: Date: First Name Middle Initial: Address: City: State: Zip: Cell Phne Number: Hme Phne Number: Email: May
Cayuga Center for Healthy Living Health and Lifestyle Questionnaire. Name: Date of Birth: Today s date: Clinic visit date:
Cayuga Center fr Healthy Living Health and Lifestyle Questinnaire Name: Date f Birth: Tday s date: Clinic visit date: Histry f weight lss/gain: Desired r gal weight: Lwest adult weight: Highest adult weight
Lower Extremity Amputation (LEA) Considerations / Issues
Lwer Extremity Amputatin (LEA) Cnsideratins / Issues Prviding Te Fillers can be an advantageus resurce fr yur patient and business but it als cmes with certain cnsideratins. Please review this list belw
Tell Us About Your Child
GIVNG TREE PEDIATRIC DENTISTRY Rebekah Tannen DDS 110 Washington Avenue Pleasantville, NY 10570 Tel: 914-579-2225 Fax: 914-579-2226 Email: Team@givingtreedental.com www.givingtreedental.com We are thrilled
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. (Print Patient s Name) (Signature-Parent/Legal
Head and neck cancers are often treated with radiotherapy. Radiotherapy can lead to faster rates of tooth decay and poor healing in the mouth.
DENTAL EXTRACTION This infrmatin aims t help yu understand the peratin, what is invlved and sme cmmn cmplicatins that may ccur. It may help answer sme f yur questins and help yu think f ther questins that
Assessment Field Activity Collaborative Assessment, Planning, and Support: Safety and Risk in Teams
Assessment Field Activity Cllabrative Assessment, Planning, and Supprt: Safety and Risk in Teams OBSERVATION Identify a case fr which a team meeting t discuss safety and/r safety planning is needed r scheduled.
NEW PATIENT QUESTIONNAIRE-ADULT
3700 WASHINGTON AVENUE EVANSVILLE, IN 47750 (812) 485-7680 NEW PATIENT QUESTIONNAIRE-ADULT PART 1. PATIENT INFORMATION Name Hme Phne Date f Birth Scial Security Number Wrk Phne Tday s Date Physicians Caring
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Patrick J McGahan, MD Orthopaedic Surgeon Specializing in Sports Medicine/Shoulder Reconstruction Surgery Instructions Hip
Patrick J McGahan, MD Orthpaedic Surgen Specializing in Sprts Medicine/Shulder Recnstructin 2801 K St, Ste 330, Sacrament, CA, 95816 (p) 916-733-5049 (f) 916-733-8914 www.patrickmcgahanmd.cm Befre Surgery
CHILDREN AGES 5 through 13 YEARS OLD Intake Questionnaire
KIDSPACE Adaptive Play and Wellness 469 Buckland Rad, Suite 102 Suth Windsr, CT 06074 CHILDREN AGES 5 thrugh 13 YEARS OLD Intake Questinnaire Tday s : / / Name: f Birth: / / Age: Gender: Street Address:
NIA Magellan 1 Spine Care Program Interventional Pain Management Frequently Asked Questions (FAQs) For Medicare Advantage HMO and PPO
NIA Magellan 1 Spine Care Prgram Interventinal Pain Management Frequently Asked Questins (FAQs) Fr Medicare Advantage HMO and PPO Questin GENERAL Why is Flrida Blue implementing a Spine Management prgram
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
A Phase I Study of CEP-701 in Patients with Refractory Neuroblastoma NANT (01-03) A New Approaches to Neuroblastoma Therapy (NANT) treatment protocol.
SAMPLE INFORMED CONSENT A Phase I Study f CEP-701 in Patients with Refractry Neurblastma NANT (01-03) A New Appraches t Neurblastma Therapy (NANT) treatment prtcl. The wrd yu used thrughut this dcument
Do you have any of the symptoms listed below? Please circle all that apply.
D yu have any f the symptms listed belw? Please circle all that apply. Parkinsn s Symptms: Truble walking Falls Feet sticking t the flr Tremr Medicatins wearing ff Truble sleeping Vivid dreams Thrashing
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer
Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic
Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
SLEEP-WAKE QUESTIONNAIRE
Shasta Critical Care Specialists Sleep Center: (530) 232-3017, 2701 Old Eureka Way, Suite 1J, Redding, CA 96001 Office: (530) 232-3000, 2701 Old Eureka Way, Suite 1E, Redding, CA 96001 Fax: (530) 242-8545
How did you hear about our office?
How did you hear about our office? Personal Information: Patient Name Social Security # Birthdate / / Address E mail Home Phone Mobile Work Employer Occupation Employer Address Spouse/Partner or Guardian
How did you hear about us? Dentist Family Friend Pediatrician Community Event Website. Internet Yellow Pages Val Pak Other
Welcome! Thank you for selecting Royal Care Dentistry, LLC.We will strive to provide you with the best possible dental care. To help meet all of your healthcare needs, please fill out this form completely
This standard operating procedure applies to stop smoking services provided by North 51.
Authr Name/Title Melanie McIlvar, Bid Develpment Manager Authr Signature Date: 4 th September 2017 Apprver Name/Title Jasn Shelley, Grup Directr f QA/RA Apprver Signature Date: 4 th September 2017 Issue
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
Reach Chiropractic Health Profile
Reach Chirpractic Health Prfile NameDate / / Age Male/Female Address City State Zip Phne: Hme Cell Cell Phne Prvider Date f Birth / / Email Address_ OccupatinEmplyer s Name Single/Married/Divrced/Widwed
Welcome to South 40 Dental! Tell Us About Yourself
Welcome to South 40 Dental! Tell Us About Yourself Name: Last First MI Title Preferred Name: Male Female Parent/Guardian Name if Under 18 Years Old: Address: City Prov. Postal Code Date of Birth (day)
CALVIN JOHNSON JR. FOUNDATION 2015 PANCREATIC CANCER RESEARCH SCHOLARSHIP
I. Intrductin CALVIN JOHNSON JR. FOUNDATION 2015 PANCREATIC CANCER RESEARCH SCHOLARSHIP The Calvin Jhnsn Jr. Fundatin, Inc. (CJJRF) is a nn-prfit 501(c)(3) rganizatin funded in 2008 by Calvin MEGATRON
Pain relief after surgery
Pain relief after surgery Imprtant infrmatin fr patients www.mchft.nhs.uk We care because yu matter This leaflet is designed t help yu cntrl any pain yu may have at hme fllwing yur peratin. Please read
FDA Dietary Supplement cgmp
FDA Dietary Supplement cgmp FEBRUARY 2009 OVERVIEW Summary The Fd and Drug Administratin (FDA) has issued a final rule regarding current gd manufacturing practices (cgmp) fr dietary supplements that establishes
Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance
1 Today s Date: 2 (225) 664-2646 (225) 664-2640 (fax) 245 VETERANS BLVD. DENHAM SPRINGS, LA 70726 Who is Accompanying Your Child Today? Name: Relation: Do you have legal custody of this child? Yes No Tell
Twohig Dentistry Dental and Oral Health Information
Twohig Dentistry Dental and Oral Health Information Patient s name: Date: Please describe any specific dental problem or discomfort you are having at this time: How long has it been present? If you have
3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA *How did you hear about our program?
3903 Fair Ridge Drive, Suite 209, Fairfax, VA 22033 44121 Harry Byrd Hwy, Suite 285, Ashburn, VA 220147 *Hw did yu hear abut ur prgram? Patient Histry Patient Name: First Middle: Last: Address: City: State: