Patients Name Date of Birth (d/m/y) Street Address City, Province Postal Code. Mailing Address if different from above. Name of Parent/Legal Guardian
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1 Patients Name Date of Birth (d/m/y) Street Address City, Province Postal Code Mailing Address if different from above Name of Parent/Legal Guardian Please check one of the following if applicable: Child is adopted/age Child lives in a Foster home Child lives with a family member other than parent Home Phone# Mobile Phone# Do you have Dental Insurance? No Primary Coverage Insurance Company Employer Policyholder Name Policyholder DOB (d/m/y) Group/Plan/Policy# Certificate/Identification/Employee# Secondary Coverage Insurance Company Employer Policyholder Name Policyholder DOB (d/m/y) Group/Plan/Policy# Certificate/Identification/Employee# Health card # Expiry Date (d/m/y) Who may we thank for referring you to our practice? Dental Office Yellow Pages Newspaper School Work Website Other
2 Dental Payment Agreement We would like to welcome you to our dental office and inform you of our policy regarding fees. For patients with dental coverage: It is not a guarantee of full payment from your insurance company. Fees vary with type of procedure and complexity of treatment. Payment for services is due at the time of treatment. As a convenience to you, our office will submit the charges to your insurance carrier. Since very few companies will cover the entire fee, we ask that you pay your percentage of the total cost, including any deductible, on the day the services are rendered. If the insurance company or MSI refuses payment, or does not pay in full, you will be responsible for the remaining outstanding balance. For patients without any dental coverage: If you do not have dental insurance, you will be expected to pay the full cost of your treatment. Payment for services is due at the time of treatment. MSI will not cover sedation fee, occlusal x-ray fee or space maintainers. We will notify you of uninsured procedures before they commence. To avoid any misunderstanding, whatever amount that your insurance or MSI does not pay, you are expected to cover. We require 48 hours notice to cancel a scheduled appointment. Should you miss an appointment without giving us notice or valid reason; there will be a charge of 100$ applied to your account. I understand and agree to the above payment agreement and policy. Signature: Date:
3 Medical History No Is your child being treated by a physician? If yes, for what? No Has your child ever been hospitalized? If yes, for what? When? No Has your child ever received general anesthesia? Were there any complications? No Has any family member had complications during general anesthesia? If yes, explain No Is your child allergic to any medication? If yes, what? No Is your child taking any medications at this time? If yes, what? No Has a Dentist or Physician warned you against giving your child any specific drug or medicine? If yes, what? No Were difficulties encountered during pregnancy? Describe No Did your child have any congenital birth defects? Describe HAS YOUR CHILD EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING CONDITIONS No Anemia No Developmentally Delayed No Jaundice No Heart Murmur No Diabetes No Measles No Asthma No Eye Problems No Mumps No Allergies No Frequent Colds No Orthopedic Problems No Bleeding Problems No Hearing Loss No Rheumatic Fever No Blood Transfusion No Hepatitis No Sickle Cell Anemia/Trait No Chicken pox No HIV (AIDS) No Other No Convulsions/Seizures No Hyperactivity Child s Physician (Pediatrician): Name of child s physician (pediatrician): Physician s Address and phone number: Date of last visit and purpose
4 Dental History How often teeth are brushed each day? Flossed? By whom? Does your child use Fluoride vitamins? Fluoride rinse/gel? Fluoride toothpaste? How many times per day does your child eat snacks? Drink sugar beverages? At what age did your child completely give up bottles/breastfeeding? Has your child had orthodontic treatment? If yes, what treatment? No Has drinking water ever been tested for fluoride? If yes, what were the results? No Is this first visit to the dentist? If no, were there any problems with previous visits? No Does your child suck a thumb, finger, or have any other oral habits? If yes, briefly describe: No Does your child have a specific dental condition about which you are concerned? If yes, briefly describe: No Has your child had any accidents involving his/her teeth? If yes, briefly describe No Has your child had a recent injury to the head, neck or jaw? Describe: No Has your child had recent involvement in an automobile or bicycle accident? Describe: PLEASE READ THE OFFICE PRIVACY STATEMENT. By signing below I declare all information I have given to be accurate. I have read, understand and agree to the privacy statement. Parent/Guardian Signature Date Dentist Signature Date
5 INSTRUCTIONS TO THE PARENTS OF CHILDREN WHO ARE TO UNDERGO SEDATION FOR DENTAL TREATMENT Dental History Our concerns are to provide high quality care and a posi ve dental experience for your child. Seda on is some mes recommended in order to helpteeth reachare these goalseach by making the dentalflossed? visit as easy and comfortable your child as How o en brushed day? By whom?for possible. Use of seda on will generally help to relieve your child of fear and anxiety. Though we do not put children to Does your child use Fluoride vitamins? Fluoride rinse/gel? Fluoride toothpaste? sleep, they o en nap lightly. A er your child is sedated we will take your child to the dental treatment room. We will closely How monitor your child while is being many mes per day treatment does your child eatcompleted. snacks? Drink sugar beverages? whataage did yourseda on child completely give up bo les/breas eeding? of the following is necessary: To helpat insure successful appointment, your understanding and coopera on your child orthodon c treatment? yes, what treatment? Has Healthy child had if your child develops a runnyif nose, a cough, or a cold, the appointment may have to be postponed. call immediately as weever maybeen havetested to reschedule when your is well. No Has Please drinking water for fluoride? If yes,child what were the results? No dairy products before appointment: To minimize nausea and vomi ng, your child is not to have dairy products for a minimum of 4 hours prior to their appointment. No Is this first visit to the den st? If no, were there any problems with previous visits? Arriving: You will be required to fill out some paperwork upon your arrival. A er consulta on and careful assessment, your child will be administered an oral seda ve. If you arrive late there may not be adequate me No appointment Does your child a thumb, finger, or have any other oral habits? If yes, briefly describe: for the andsuck you may have to be rescheduled. Medica ons: If your child is taking any medica ons, please contact the office prior to appointment. Do No not Does give your other medica ons day of their including Tylenol, Advil, Gravol, or yourchild childany have a specific dentalthe condi on aboutappointment, which you are concerned? If yes, briefly cough medicine. describe: Favorite toy or blanket: It is o en relaxing for your child to bring a favorite toy or blanket to have during the No Has your child had any accidents involving his/her teeth? If yes, briefly describe treatment Monitoring: A er seda on has been given, your child will wait in the wai ng room un l she/he is ready for treatment. During thishad me, you are responsible for your No Has your child a recent injury to the head, neckchild. or jaw? Describe: Other children and appointments: Since an adult must accompany your child during the me required for the No Has your child had recent involvement in an automobile or bicycle accident? Describe: medica on to become effec ve, the company of other siblings and the scheduling of other appointments is not advisable. O en mes your child is at our office for two or three hours. Seda on Fee: There will be a seda on fee due the day of appointment. PLEASE Dental READ Insurance: PrivatePRIVACY dental insurance and/or MSI will o en cover the cost of dental treatment for children THE OFFICE STATEMENT. th un l the month of their 15 birthday. A er this me, there will be a charge for services not covered by private By signing below all informa on have to be accurate. I have read, understand and agree insurance. PleaseI declare be prepared to pay the Iday ofgiven appointment. to the privacy statement. Cancella ons: Our office requires at least 48 hours no ce to cancel an appointment. Please note that a $ cancella on fee will apply with inadequate no ce or failure to a end an appointment. Also if we do not have a Parent/Guardian Signature Date current phone number and cannot confirm your appointment the appointment will not be held. Den st Signature Date Please feel free to call our office with any ques ons or concerns.
Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
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Child Health/Dental History Form
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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
New Patient Information
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Tell Us About Your Child
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Chapel Hill Pediatric Dentistry
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Tell Us About Your Child
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Address (if different from above):
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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
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PATIENT REGISTRATION FORM
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----PATIENT INFORMATION---- Patient s Full Name Preferred Name DOB Age Sex. School Grade. Residence Address. City State Zip Home Phone #
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Get Acquainted Questionnaire Tell Us About Your Child!
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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
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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
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MEDICAL AND PERSONAL HISTORY
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Patient s Full Name Age Sex: (M) (F) Whom may we thank for referring you?
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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
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
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:
Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
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Patient Registration
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New Patient Information
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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:
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PATIENT HEALTH HISTORY
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Names and ages of other children in family School Grade. Employer Phone
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DENTAL INSURANCE Name Employer Name Policy Holder Name Policy Holder Birthdate Policy Number Group Number Social Security Number
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PATIENT REGISTRATION
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Patient Registration
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GET ACQUAINTED QUESTIONNAIRE
Aparna Aghi, D.M.D., M.S. tel. 415.459.1444 fax 415.453.1320 www.openbigdds.com Assistant Professor Pediatric Dentistry UCSF School of Dentistry Martin Sinai Rayman, D.D.S. Diplomate American Board of
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Last 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:
Child 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
Patient 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
PATIENT 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
General 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
DENTAL DIAGNOSIS AND TREATMENT
OFFICE POLICIES EXPECTED PAYMENT In order to keep our fees as low as possible we ask that co payments be paid at the time of service. For your conveniene an estimate for dental care will be prepared prior
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
COLVIN 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
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
Prosthodontics 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
HEALTH 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 #:
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Personal 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
Village 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,
Children s Intake: 0-12 years of age
Julie Lachman, ND 196 W. Ashland St. Doylestown, PA 18901 phone: (267) 895-1733 fax (888) 972-5592 Children s Intake: 0-12 years of age First Name: Last Name: Date: Address: City: State: Zip: Preferred