TODAY S DATE FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? SOCIAL SECURITY #
|
|
- Erick Moore
- 5 years ago
- Views:
Transcription
1 PATIENT INFORMATION PATIENT NAME FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? HOME ADDRESS TEXT REMINDERS DATE OF BIRTH YES NO SOCIAL SECURITY # PHONE HOME EMPLOYER/OCCUPATION EMERGENCY CONTACT BUSINESS MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED MOBILE GENDER MALE FEMALE FIRST LAST PHONE RELATION TO PATIENT WITH WHOM ARE WE ALLOWED TO SPEAK ABOUT YOUR DENTAL HEALTH (IN ADDITION TO PARENT, GUARDIAN, INSURANCE) ARE ANY FAMILY MEMBERS PATIENTS WITH US? WHO? WHOM MAY WE THANK FOR REFERRING YOU? BILLING INFORMATION PERSON RESPONSIBLE FOR ACCOUNT FIRST LAST PHONE RELATION TO PATIENT ADDRESS DATE OF BIRTH SOCIAL SECURITY # EMPLOYER NAME EMPLOYER ADDRESS INSURANCE INFORMATION We provide the courtesy of filing insurance claims on your behalf. Please provide your insurance ID card at the time of registration. POLICY HOLDER PATIENT RESPONSIBLE PARTY DENTAL INSURANCE COMPANY PHONE ADDRESS INSURANCE PLAN NAME INSURANCE ID NUMBER GROUP ID UNION OR LOCAL NAME - Page 1 of 9 -
2 MEDICAL HISTORY NAME OF PERSON COMPLETING FORM RELATION TO PATIENT PHYSICIAN NAME PHYSICIAN PHONE OTHER PHYSICIANS APPROXIMATE DATE OF LAST PHYSICAL HEIGHT WEIGHT LIST ANY CONDITIONS OR ILLNESS FOR WHICH YOU ARE BEING TREATED: DESCRIBE ANY TREATMENT RECIEVED IN A HOSPITAL OR EMERGENCY ROOM WITHIN THE LAST TWO YEARS: LIST ANY PREVIOUS SURGERIES WITH APPROXIMATE DATES (e.g. Back surgery, gall bladder, tonsillectory, prosthetic joint replacement) DESCRIBE ANY CURRENT CONDITIONS THAT CAN BE SPREAD BY COUGHING: FOR WOMEN ARE YOU PREGNANT (OR THINK YOU MAY BE)? YES NO ARE YOU TAKING BIRTH CONTROL PILLS? YES NO ARE YOU NURSING? YES NO INDICATE ANY ALLERGIES TO THE FOLLOWING: ASPIRIN PENICILLIN LATEX IODINE DYE CODEINE SULFA DENTAL RESTORATIVE MATERIALS PLEASE LIST ANY OTHER ALLERGIES CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV POSITIVE ANEMIA ARTHRITIS, RHEUMATISM ARTIFICIAL HEART VALVE ARTIFICIAL JOINTS ASTHMA AUTOIMMUNE DISEASE BACK PROBLEMS BISPHOSPHONATE BLOOD DISEASE CANCER CHEMICAL DEPENDENCY CHEMO/RADIATION THERAPY CIRCULATORY PROBLEMS CORTISONE TREATMENTS COUGH, PERSISTENT COUGH UP BLOOD DIABETES EPILEPSY FAINTING GASTROINTESTINAL DISORDER GLAUCOMA HEADACHES HEART MURMUR HEART PROBLEMS, DESCRIBE HEMOPHILIA HEPATITIS A/ B /OTHER HIGH BLOOD PRESSURE JAW PAIN KIDNEY DISEASE LIVER DISEASE MITRAL VALVE PROLAPSE NERVOUS PROBLEMS PACEMAKER PSYCHIATRIC CARE RADIATION TREATMENT RESPIRATORY DISEASE RHEUMATIC FEVER SCARLET FEVER SHORTNESS OF BREATH SKIN RASH SLEEP APNEA STROKE SWELLING OF FEET/ANKLES THYROID PROBLEMS TOBACCO HABIT TUBERCULOSIS ULCER VENEREAL DISEASE DESCRIBE ANY OTHER MEDICAL CONDITIONS WE SHOULD BE AWARE OF: - Page 2 of 9 -
3 MEDICAL HISTORY (CONT.) PREFERRED PHARMACY PHARMACY PHONE ADDRESS DO YOU TAKE ANY OF THESE ANTICOAGULANTS? ASPIRIN PLAVIX ELIQUIS XARELTO PRADAXA DO YOU TAKE COUMADIN (BLOOD THINNER)? YES NO DO YOU TAKE STEROID MEDICATION? YES NO DO YOU TAKE DRUGS TO SUPPRESS THE IMMUNE SYSTEM? YES NO HAVE YOU EVER TAKEN BIPHOSPHONATES FOR OSTEOPOROSIS OR FOR CHEMOTHERAPY YES NO TO TREAT MULTIPLE MYELOMA? OTHER OVER THE COUNTER AND PRESCRIPTION DRUGS CURRENT VITAMINS, HERBALS, OR OTHER REMEDIES DO YOU CONSUME ALCOHOL? NONE SOCIAL USE MORE THAN SOCIAL USE DO YOU USE TOBACCO PRODUCTS? NONE CIGARETTE CIGAR PIPE SMOKELSS DO YOU USE STREET DRUGS? NONE MARIJUANA COCAINE METHAMPHETAMINE HEROINE OTHER HEALTH RISK ASSESSMENT DO YOU HAVE DIFFICULTY CONCENTRATING OR STAYING AWAKE DURING THE DAY? NO YES DO YOU HAVE OR ARE BEING TREATED FOR HIGH BLOOD PRESSURE? NO YES DO YOU SNORE LOUDLY? NO YES DO YOU WEAR A C-PAP OR SLEEP APPLIANCE? NO YES ARE YOUR TONSILS PRESENT? NO YES DESCRIBE YOUR SLEEP POSITION: SIDE FRONT BACK To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform my doctor at the next appointment. Print Name Signature of Patient, Parent, or Guardian Date - Page 3 of 9 -
4 DENTAL HISTORY HOW CAN WE HELP YOU TODAY? DO YOU HAVE ANY TOOTH OR ORAL PAIN? YES NO IF YES, WHERE IS THE PAIN? ARE YOU TAKING PAIN MEDICATION FOR ORAL PAIN? YES NO IF YES, WHAT MEDICATION? ARE YOU TAKING ANTIBIOTICS FOR ORAL INFECTION? YES NO IF YES, WHICH ANTIBIOTIC? CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: BAD BREATH BITE PROBLEMS BROKEN FILLINGS BROKEN TEETH CAVITY PROBLEMS CHEWING PROBLEMS GUM PROBLEMS MISSING TEETH SMILE/COSMETIC ISSUES OLD FILLINGS WHICH SHOULD BE EVALUATED ORAL CARE HABITS WHEN WAS YOUR LAST DENTAL VISIT? WHAT WAS DONE AT THAT VISIT? CLEANING FILLING/CROWN/BRIDGE DENTURE/PARTIAL EVALUATION EXTRACTION GUM TREATMENT ROOT CANAL UNCERTAIN WHEN WERE YOUR LAST DENTAL X-RAYS TAKEN? HOW OFTEN DO YOU SEE A DENTIST FOR ROUTINE CARE? ANNUALLY ONLY FOR PAIN TWICE A YEAR SELDOM 3 OR 4 TIMES A YEAR NEVER HOW MANY CAVITIES HAVE YOU HAD RECENTLY? NONE 2 OR LESS IN PAST THREE YEARS THREE OR MORE DURING THE LAST THREE YEARS UNCERTAIN HAVE YOU LOST ANY TEETH BESIDES YOUR BABY TEETH? NO YES IF APPLICABLE, CHECK THE REASON FOR LOSS: WISDOM TEETH EXTRACTED EXTRACTED DUE TO DECAY EXTRACTED DUE TO GUM PROBLEM FOR ORTHODONTIC CARE DUE TO AN ACCIDENT REASON NOT LISTED HOW IS YOUR FAMILY S DENTAL HEALTH? MOST HAVE GOOD TEETH MOST HAVE BAD TEETH HISTORY OF DENTURES HISTORY OF TOOTH LOSS HISTORY OF GUM UNCERTAIN DISEASE - Page 4 of 9 -
5 DENTAL HISTORY (CONT.) WHAT ARE YOUR BRUSHING HABITS? ONCE PER DAY TWICE PER DAY THREE TIMES PER DAY SELDOM NEVER NOT APPLICABLE WHAT TYPE OF TOOTHBRUSH DO YOU USE? HARD MEDIUM SOFT SONICARE ELECTRIC/ROTARY UNCERTAIN NOT APPLICABLE HOW MANY TIMES A DAY DO YOU EAT OR DRINK ITEMS CONTAINING SUGAR? LESS THAN 3 TIMES MORE THAN 3 TIMES MORE THAN 5 TIMES NONE IS THE WATER AT YOUR HOME FLUORIDATED? YES NO UNCERTAIN DO YOU FLOSS YOUR TEETH? DAILY WEEKLY OCCASIONALLY SELDOM NEVER NOT APPLICABLE DO YOU USE OTHER ORAL CLEANING PRODUCTS? WATERPIK MOUTH RINSE TOOTHPICK NOT APPLICABLE DOES YOUR MOUTH FEEL DRY MOST OF THE TIME? NO YES NOT APPLICABLE IF SO, IS YOUR DRY MOUTH A NEW EXPERIENCE? NO YES NOT APPLICABLE WHAT IS THE SEVERITY OF YOUR DRY MOUTH? MILD MODERATE SEVERE HAVE YOU EXPERIENCED ANY ALTERATION IN YOUR TASTE PERCEPTION? NO YES ARE THERE PHYSICAL OR MENTAL LIMITATIONS PREVENTING ORAL HYGIENE? NO YES PERIODONTAL (GUM) HEALTH ARE THERE PHYSICAL OR MENTAL LIMITATIONS PREVENTING ORAL HYGIENE? NO YES DOES FOOD GET STUCK BETWEEN YOUR TEETH? NO YES, A FEW PLACES YES, IN MANY PLACES NOT APPLICABLE DO YOUR GUMS EVER BLEED WHEN BRUSHING YOUR TEETH? NO OCCASIONALLY YES NOT APPLICABLE ARE ANY OF YOUR TEETH LOOSE? NO YES IF YES, WHERE? ARE YOU CONCERNED ABOUT RECEDING GUMS? NO YES IF YES, WHERE? CHEWING ABILITY CAN YOU CHEW YOUR FOOD WELL? YES NO NOT WELL NOT APPLICABLE CAN YOU CHEW HARD FOOD COMFORTABLY? YES NO DO YOU HAVE PARTIALS OR DENTURES? NO YES IF YOU DO, DO THEY WORK WELL? YES NO NOT WELL ARE YOUR TEETH VERY SENSITIVE TO HOT OR COLD? NO YES SOMETIMES NOT APPLICABLE DO YOU HAVE ANY ACHES OR PAINS IN YOUR JAWS OR EARS? NO YES DO YOU HAVE ANY JAW CLICKING OR POPPING? NO YES ARE YOU AWARE OF ANY HABITS OF GRINDING OR CLENCHING? NO YES ARE YOU INTERESTED IN REPLACING LOST TEETH? NO YES UNCERTAIN SMILE DO YOU LIKE YOUR SMILE? YES NO WOULD LIKE WHITER TEETH WOULD LIKE TO DISCUSS SMILE UNCERTAIN - Page 5 of 9 -
6 DENTAL HISTORY (CONT.) PAST DENTAL CARE DO YOU LIKE YOUR SMILE? YES NO WOULD LIKE WHITER TEETH WOULD LIKE TO DISCUSS SMILE UNCERTAIN HAVE YOU EVER HAD TROUBLE WITH A PREVIOUS DENTAL TREATMENT? PREVIOUS DENTIST: NO YES IF YES, PLEASE DESCRIBE: CITY: STATE: PHONE: WHY ARE YOU CHANGING? HAVE YOU EVER HAD ROOT CANAL TREATMENT? NO YES UNCERTAIN HAVE YOU EVER HAD PERIODONTAL (GUM) TREATMENT? NO YES UNCERTAIN HAVE YOU EVER HAD BRACES? NO YES UNCERTAIN HAVE YOU EVER HAD YOUR TEETH GROUND OR YOUR BITE ADJUSTED? NO YES UNCERTAIN BREATH ODOR DO YOU HAVE A PROBLEM WITH BAD BREATH ODOR? NO YES DENTAL CARE ANXIETY PLEASE CHECK ANY OF THE FOLLWING THAT DESCRIBE YOU: DENTAL CARE DOES NOT FRIGHTEN ME I AM FRIGHTENED OF DENTAL CARE I HAVE EXTREME DENTAL PHOBIA LOCAL ANESTHESIA WORKS WELL FOR ME A RELAXATION PILL HELPS ME WITH DENTAL CARE NITROUS OXIDE (LAUGHING GAS) HELPS ME TOLERATE DENTAL CARE I REQUIRE IV SEDATION OR GENERAL ANESTHESIA OTHER MATTERS YOU WOULD LIKE TO TELL US ABOUT DO YOU HAVE OTHER PROBLEMS YOU WOULD LIKE TO TELL US ABOUT WHICH HAVE NOT BEEN IDENTIFIED? - Page 6 of 9 -
7 CONSENT FOR SERVICES 1. I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis. Initial: 2. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. Initial: 3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication. Initial: 4. I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. Initial: 5. I hereby give the doctor the absolute right and permission to use my photograph/slides for education or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides. Initial: 6. I acknowledge that I reviewed Loyalsock Dental Associates HIPAA and Notice of Privacy Practices. A copy is available upon request. Initial: Signature of Patient, Parent, or Guardian Date Relationship to Patient - Page 7 of 9 -
8 PATIENT PRIVACY RELEASE FORM I consent to disclosure of the following protected health information about me to the following family members, medical or dental providers (involved in my dental care such as referring doctors), or persons (insurance companies) involved in my care or payment of my care for the following that may apply: All dental/medical information Information necessary to schedule appointments for me Lab results/radiographs Information necessary to provide for calling in or picking up prescriptions Information necessary to my family members, persons, and dental/medical providers Information necessary to bill for or submit claims for care provided for me by my dental insurance or FSA accounts I authorize this Health Provider and/or staff to leave medical or account information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes: Home/Cell Telephone Yes No Work Telephone Yes No Please list names of authorized persons: Rights of the patient I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclose in this document by sending written authorization to Joyce Kim, DDS. I understand that I have the right to refuse to sign this authorization and that any treatment will not be conditioned on sighing this authorization. This authorization shall be effective until revoked by the patient or representative signing the authorization. Signature of Patient/Parent/Guardian Date - Page 8 of 9 -
9 RECORDS RELEASE FORM I,, authorize Loyalsock Dental Associates to request the following records from my previous dentist. Previous Dentist: Name: Address: City: Phone: Fax: Please note that Loyalsock Dental Associates is requesting the following records: 1. All x-rays from the last five years 2. All perio readings 3. Recommended treatment and treatment plans Signature Date Note to patients: Please send this form back either by fax to: or scan and to before your appointment. Note to doctor: Loyalsock Dental Associates is a chartless office and would prefer that the above records be sent via to the loyalsockdental@gmail.com. Records may also be sent to: Loyalsock Dental Associates 1501 Washington Blvd. Williamsport, PA Page 9 of 9 -
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
More informationNew 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
More informationPATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
More informationKingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
More informationJulia A. Hallisy, D.D.S., Inc.
Julia A. Hallisy, D.D.S., Inc. Welcome! Thank you for choosing our office for your dental health needs. Please let us know if you need assistance when completing these forms. Name PATIENT INFORMATION Last
More informationTwohig 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
More informationPatient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
More informationPatient Registration
P A R K S I D E D E N T A L C A R E 37 Newbury Street 3 rd Floor Boston MA 02116 617.426.5549 phone 617.426.1186 fax www.flossboston.com parksidedentalcare@yahoo.com Patient Registration First Name: Middle:
More informationPatient 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
More information3. 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
More informationWELCOME 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
More informationPATIENT 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
More informationMEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
More informationPATIENT HEALTH HISTORY
PATIENT HEALTH HISTORY Patient Name Today s Date Birthdate DENTAL HISTORY Reason for Today s Visit Are you having dental pain now? Former Dentist Date of last dental visit Last x-rays Check (!) if you
More informationPATIENT 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:
More informationLast Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
More informationMarried Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
More informationAJ Dental Group, PC Family, Cosmetic & Implant Dentistry
: Patient s Name: Social Security #: How do you wish to be addressed? of Birth: Age: Male Female Minor Single Married Separated Divorced Widowed No answer Residence Street Address: _ City: State: Zip code:
More informationLake Forest Dental. Patient Information
Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
More informationProsthodontics and Implant Surgery
Prosthodontics and Implant Surgery www.simplyradiantsmile.com Patient Name: Date: Last First MI How would you prefer to be addressed? Male Female Age: Married Single Child Other Social Security #: Birth
More informationYes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
More informationMedical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
More informationPatient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
Patient Registration (complete form must be filled to process insurance claim) Patient Information First Name: Last Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Would you
More informationLake Forest Dental. Patient Information
Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
More informationATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Responsible Party Address City State Sex M F Age Birthdate Married Widowed Single Minor Separated
More informationPATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
More informationACKNOWLEDGEMENT 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
More informationPatient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: Address: Birthdate: Age: Social Security Number:
Date: PATIENT REGISTRATION Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail Address: Birthdate: Age: Social Security Number: Patient s Employer: Male: Female:
More information(Please complete the enclosed forms prior to your visit and bring them in with you.)
Hello! We would like to extend to you a very warm welcome to our dental practice. We are committed to doing everything possible to provide you with high quality dental care and also make your visit to
More informationA B O U T Y O U D E N T A L I N F O R M A T I O N
1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:
More informationPATIENT INFORMATION DENTAL HEALTH HISTORY
PATIENT INFORMATION Welcome to Pristine Family and Implant Dentistry. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following
More informationWelcome 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)
More informationPATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
More informationPatient Information. Spouse or Responsible Party Information. Insurance Information
Patient Information Full Name Preferred Name Home Address City, St, Zip Home Phone # E-Mail Address Employed By Work Phone # Occupation Pager/Cell Phone # Male Female Birth Social Security # Married Single
More informationSTEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
More informationMEDICAL 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
More informationRegistration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
More informationPATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
More informationPatient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
Patient Registration Patient s Full Name: Home Address: Home Phone Number: Cell Phone Number: Social Security #: DOB: Relationship Status: Married Divorced Single Place of Employment: Work Address: Work
More informationPATIENT S NAME GENDER First Middle Init. Last Male/Female. Home Address. PATIENT EMPLOYER Bus. Phone. Employer Address. NAME OF SPOUSE Birth Date
PATIENT INFORMATION RECORD The following information is needed for our records. Please print answers to all questions. PATIENT S NAME GENDER First Middle Init. Last Male/Female Birth Age Marital Status
More informationSorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA 93442 (805) 772-8585 Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone
More informationKODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
More informationNEW Adult Patient Information
NEW Adult Patient Information Patient Information Patient s Name: last first middle likes to be called Date of Birth: Age: Sex: E-Mail: Phone: Cell Phone/Alternate Phone: Home Address: Marital Status:
More informationEmergency Contact Information: Name Address Phone Number. How did you hear about our office? Reason for your visit today?
Welcome to Our Office! Patient Registration Paul S. Jackson, D.M.D. 1345 E. Fort Union Blvd. Salt Lake City, Utah, 84121 Patient s Name Birth Date Age Gender Home Address City State Zip Home Phone Cell
More informationMEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
More informationPatient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
Amir Mojaver, D.M.D. Leading Edge Dentistry for the Quality Minded Individual. PATIENT INFORMATION Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
More informationJennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
Jennifer Unger Waters, D.D.S., P.C. 1607 Washington Avenue Golden, CO 80401 (303)279-6621 WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely
More informationMEDICAL HISTORY. PATIENT NAME Birth Date
TIME 10:17 AM Lund Dental Associates DATE 8/26/2013 MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire
More informationWelcome 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
More informationGENERAL QUESTIONS CONTACT INFORMATION
GENERAL QUESTIONS Purpose of this visit: Today s date: Are you currently experiencing any dental pain? Date of last dental visit: Date of most recent dental x-rays: CONTACT INFORMATION Last Name: Telephone
More informationPreferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:
ID: PATIENT REGISTRATION DATE First Name: Patient Is: Policy Holder Responsible Party Last Name: Preferred Name: Middle Initial: Responsible Party (if someone other than the patient) First Name: Last Name:
More informationDear Patient, Sincerely, Dr. Edward Adourian. carlsbaddentalassociates.com. Dental Associates & Orthodontics EXCELLENCE IN DENTISTRY
EXCELLENCE IN DENTISTRY Dear Patient, It is with great pleasure that we welcome you to our dental practice at Carlsbad Dental Associates. We want you to know that we appreciate the opportunity to take
More informationPersonal Information Protection Act Consent Form
Personal Information Protection Act Consent Form Lloydminster Denture Clinic Inc. In our office, we are dedicated to ensuring the protection of our patients personal information and insuring that this
More informationDENTAL QUESTIONNAIRE
Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
More informationTuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,
Tuolumne Me-Wuk Dental Clinic 19969 Greenley Road, Suite D Sonora CA 95370 Phone: 209-532 0034 Fax: 209-532 0036 Dear Patient, Welcome to the Tuolumne Me-Wuk Dental Clinic. We are a department of the Tuolumne
More informationANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!!
BILL ANDERSON DDS, AUSTIN HOFFNER DDS 1401 East Sandusky St. Findlay Ohio 419-424-5850 ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!! Thank you for choosing our office! We strive to deliver high quality
More informationWe Would Like to Get to Know You Better!
We Would Like to Get to Know You Better! Date Full Name Phone (Hm) ( ) - (Wk) ( ) - Address City State Zip Email Date of birth Social Security # - - Drivers License # Marital status Spouse s name Occupation
More informationLast Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name:_ Address: City:_
More informationUpperman Family Dental NEW PATIENT REGISTRATION
Date Upperman Family Dental NEW PATIENT REGISTRATION First Name Middle Initial Last Name Patient is: Policy Holder Responsible Party Preferred Name Address Address 2 City, State, Zip Home Phone Cell Phone
More informationName: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:
Lake Pointe Dental Group Dr. Shannon Maddox and Team www.lpfdokc.com 10914 Hefner Pointe Drive, #150 (405)946-5558 Oklahoma City, OK PLEASE COMPLETE AND RETURN TO BUSINESS OFFICE Name: Last First Middle
More informationPATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:
PATIENT FORMS Patient Information Name: Birth Date: Social Security #: Home Phone: Cell Phone: Email: Address: City: State: Zip: Responsible Party Name of person responsible for this account: Relationship
More informationAccess Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-
Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS- REFERRED BY: TODAY S DATE: PATIENT NAME HOME PHONE (LAST) (FIRST) (MIDDLE) E-MAIL CELL PHONE HOME ADDRESS (STREET) (CITY) (STATE)
More informationMedical Health Information (continued):
Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present
More informationWelcome to Dr. Halliday s Office
Dentist Medical Dr. Welcome to Dr. Halliday s Office Patient information: Today s Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Home Tel.( ) Cell.( ) Have you
More informationPAUL T. OLENYN D.D.S.
PAUL T. OLENYN D.D.S. WWW.SMILESBYDROLENYN.COM 5207 Lyngate Ct Burke, Virginia 22015 PATIENT INFORMATION Tel: 703 978 8560 Date: NEW PATIENT UPDATE Patient: LAST FIRST MI MALE FEMALE CHILD* STUDENT** SINGLE
More informationCOLVIN AVENUE DENTAL. Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York WELCOME LETTER. Dear
WELCOME LETTER Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York 12206 518-459-7993 Dear Welcome to our dental practice. Our dedicated and experienced team has been providing quality and comfortable
More informationFairfax Oral and Maxillofacial Surgery
Fairfax Oral and Maxillofacial Surgery Patient information: Today s Date Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Sex: Male Female Birth Date Age Soc. Sec. # E-mail Street Apt. City State Zip
More informationJason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology
Jason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology Patient Information Patient Name: of Birth: Gender (M/F): Name of Parent (if patient is a minor): Home Address:
More informationAddress, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
GETTING TO KNOW YOU Welcome to transcendentist and the office of Dr. Fred Pockrass! We are committed to your total wellbeing and to helping you take the best care of your mouth. We know this is an extensive
More informationWelcome to the office of
Welcome to the office of Date: 8340 Cleveland Avenue N. Canton, Ohio 44720 330.494.6305 PERSONAL INFORMATION (Please Print Legibly) Last Name: First Name: _ Middle Initial: _ SS #: _ I would prefer to
More informationREGISTRATION AND HEALTH HISTORY
REGISTRATION AND HEALTH HISTORY Name: Social Security #: Name we should call you: Date of Birth: Home Phone #: Cell #: E-mail Address: Address: Employed By: Position: Work Phone# Marital Status: Spouse
More informationMEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
More informationHow 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
More informationPatient 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
More informationWhite House Dental 347 West Idaho Avenue Ontario, Oregon (541) whitehousedental.net
White House Dental 347 West Idaho Avenue Ontario, Oregon 97914 (541) 889-8837 whitehousedentistry@gmail.com whitehousedental.net Welcome to our office! Please help us by filling out the following form
More informationCreating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
More informationNew Patient Registration Form
New Patient Registration Form Welcome to ABC Dental Office! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
More informationHEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
More informationPatient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
More informationHighland Colony Dental- Donald K. Givan, DMD
Highland Colony Dental- Donald K. Givan, DMD 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
More informationPatient Medical and Dental History Personal Information. Name Date
Patient Medical and Dental History Personal Information Name Date (Last) (First) (Middle) Address County City State Zip Day Phone Evening Phone Cell Phone Birth Date Age Occupation Sex M or F Social Security
More informationPatient Registration Form
Patient Registration Form Patient Information Date Name: I Prefer to be called: Address: City: State: Zip: Phone ( ) Work Phone ( ) Cell Phone ( ) The best time to contact me is: A.M. P.M. on my Home phone
More informationDental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.
(847)392-4422 afgd 1307@gmail.com Dental History What is the reason for your visit today? Date of Last Dental Visit: Last Dental Cleaning Last set of X-rays What was done at your last dental visit? Q Cleaning
More informationEmployment Information Patient Employed By: Occupation: Phone: Work Mailing Address:
Patient Information Patient Name: Today s : Dr. Mr. Mrs. Ms. Prefered Name: Maritial Status: Married Single Divorced Separated Widowed Sex: Male Female Address: Social Security #: of Birth: Home Phone:
More informationPatient Name: D.O.B. Who may we thank for recommending us: Name of Dentist: Date of last visit:
Just Orthodontics Jeffrey K Just, D.D.S., S.C. Phone: 920-682-7616 Fax: 920-682-4361 www.justorthodontics.com Patient Name: D.O.B. Who may we thank for recommending us: Name of Dentist: Date of last visit:
More informationNew 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
More informationPATIENT 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
More informationPERSON RESPONSIBLE FOR PAYMENT Daytime ph Address Driver License State # City State Zip Employed by Or Retired from Address Address
Patient Information Please Print NAME Referred to us by of birth Age Single Married Divorced Widowed Separated Minor (under 18) Full time student Parent/Guardian if minor Address Home ph City State Zip
More informationKids 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 #: (
More informationMEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline
More informationChild Dental Registration
Child Dental Registration Patient Information Patient Name DOB / / Male Female Address City State Zip School Patient Lives: With Both Parents With Mother With Father Other Parent/Guardian Information Parent/Guardian
More informationChapel 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
More informationFacebook. Jamboree Dentistry Website. Insurance. Mailer. Internet Search. Community Impact Newspaper Ad. Walk In. Online Appointment Request
On behalf of all our doctors and staff, we would like to personally welcome you to Jamboree Dentistry. The highest compliments we can receive are when our patients show a vested interest in establishing
More informationVillage Dental at Olde Raleigh Patient Registration
Village Dental at Olde Raleigh Patient Registration To our New Patients: We are thrilled you have chosen us to provide you with excellent dental care! We understand dentistry can sometimes be expensive,
More informationDental Patient Survey
Dental Patient Survey Please assist us in making your in-office experience a memorable one Please indicate your language of preference: English Spanish Chinese Other 1. Where did you find us: Our website
More informationTell 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
More informationPATIENT REGISTRATION
PATIENT REGISTRATION PATIENT INFO (PLEASE PROVIDE US WITH A COPY OF YOUR PICTURE ID AND INSURANCE CARD) DATE FIRST NAME LAST NAME PREFERRED NAME GENDER ADDRESS CITY/STATE/ZIP HOME PHONE _ CELL PHONE _
More informationDavid Palmieri, D.M.D., M.S., LTD., Frank R. Portell D.M.D.,M.S. & Nathan Schoenly, D.D.S. Please Check: Mr. Ms. Mrs. Dr. Fr. Sr. Hon.
David Palmieri, D.M.D., M.S., LTD., Frank R. Portell D.M.D.,M.S. & Nathan Schoenly, D.D.S. PATIENT REGISTRATION Please Check: Mr. Ms. Mrs. Dr. Fr. Sr. Hon. OTHER: Your Name (first name) (middle int.) (last
More informationPATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
PATIENT INFORMATION SHEET Referred By: Patient s Name: SSN: Date of Birth: Address: City/Zip: Phone #: Sex: M / F Marital Status: M / S / W / D No. of Dependents: Email Address: Emergency Contact Person:
More informationGeneral Dental Treatment Consent Form
General Dental Treatment Consent Form I authorize dental treatment including necessary or advisable examination, radiographs (x-rays), diagnostic aids or local anesthesia. In general terms, dental treatment
More information