DENTAL QUESTIONNAIRE
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- Randolph Holland
- 5 years ago
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1 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) Address: ( will be used for electronic communication) Emergency Contact Name: Relation: Phone: Whom may we thank for your referral? Friend/Co-worker: Family member: Previous dentist name or dental office: DENTAL QUESTIONNAIRE When was your last dental visit: 6 months 1 year 2 years 3 years + When were your last x-rays taken: 6 months 1 year 2 years 3 years + When was your last dental cleaning: 6 months 1 year 2 years 3 years + Are you currently in any discomfort/pain with your teeth or gums? No Yes Do your gums ever bleed? No Yes Have you ever fainted or had complications following dental treatment? No Yes Have you ever had an injury, surgery, or x-ray therapy to the face or jaw? No Yes Do you have any pain in your jaw? No Yes Do you clench or grind your teeth? No Yes Are you unhappy with your smile? No Yes Would you like to have straighter teeth? No Yes Would you like to have whiter teeth? No Yes Nervous or anxious about dental treatment? No Mild Moderate Severe How would you describe the current condition of your oral health? Poor Fair Good Excellent
2 MEDICAL QUESTIONNAIRE Please check all that apply to you: AIDS/HIV GLAUCOMA RADIATION TREATMENT ALCOHOL OR DRUG ABUSE GROWTHS OR TUMORS RESPIRATORY PROBLEMS ANEMIA HEAD INJURIES RHEUMATIC FEVER ARTHRITIS HEART DISEASE SINUS PROBLEMS ARTICIFIAL VALVES/JOINTS/PINS HEART MURMUR SMOKER ASTHMA (INHALER Y/N) HEPATITIS (TYPE ) STD/VENEREAL DISEASE BLOOD DISORDER/TRANSFUSION HIGH/LOW BLOOD PRESSURE STOMACH PROBLEMS CANCER/CHEMOTHERAPY JAUNDICE STROKE CONGESTIVE HEART FAILURE KIDNEY DISEASE THYROID DISEASE DIABETES (INSULIN Y/N) LIVER DISEASE TMJ PROBLEMS DIZZINESS/FAINTING MENTAL/NERVOUS DISORDER TUBERCULOSIS EPILEPSY PACEMAKER ULCER EXCESSIVE BLEEDING PREGNANT (Y/N) BREASTFEEDING (Y/N) BIRTH CONTROL (Y/N) Do you require PREMEDICATION such as antibiotic coverage for dental treatment due to a heart condition and/or artificial joints? No Yes Do you have ALLERGIES to? ASPIRIN TYLENOL CODEINE/MORPHINE LATEX SEASONAL ANTIBIOTICS: SPECIFIC FOOD: OTHER: Family Doctor: Phone: Have you been under the care of a physician recently? Explain Have you been admitted to a hospital for major surgery in the last 2 years? Explain Have you ever had an infectious disease? Y/N Have you ever travelled to an area with infectious disease? Y/N List all medications, pills, vitamins or herbs you are presently taking:
3 Welcome to Seton Family Dental Centre! Our Appointment Policy Thank you for allowing us the privilege of being your dental health provider. Our practice is dedicated to quality care and is pleased to reserve time exclusively for each patient. We respect our patients' time and make every effort to remain on schedule. Despite careful scheduling, dental emergencies can cause delays. If your appointment time is affected due to an unforeseen emergency, we will try our best to notify you in advance. We know that your time, like our doctor s, is valuable and we will make every effort to see you on time and will ensure you are given the same time and attention for your dental health. Because we reserve time exclusively for you, we ask that you make every effort to keep your reserved appointment time. If you find that you cannot keep your scheduled visit, we require a minimum of 2 business days notification. Advance notice allows our office to see other patients who may have been waiting to see us for necessary treatment. We thank you in advance for your consideration. A charge of $75.00 will apply to your account if sufficient notice is not provided. This charge is at the discretion of your doctor. Consent for Treatment/Accountability Confirmation To the best of my knowledge all of the preceding answers and information provided are true, complete and accurate. I grant permission to you and your assignees to telephone or me to discuss matters related to this form. I understand that this information is held in the strictest confidence and it is my responsibility to inform the office of any changes to my medical status. I authorize the dental office to perform any necessary dental services that I may need during diagnosis and treatment with my written or verbal informed consent. I, the undersigned, clearly understand all policies of Seton Family Dental Centre. I understand and agree to pay all fees associated with my dental treatment. With or without dental coverage, I agree to make myself aware of those fees prior to any dental treatment I authorize to be done. Signature of Patient/Guardian Printed Name Date
4 Financial Policies for Dental Patients Your dental insurance policy is an agreement between you and your insurance company, and we will be happy to assist you in preparing and sending in the necessary forms. Please remember that no insurance company attempts to cover all dental costs. We cannot render dental treatment on the assumption that our dental fees will be paid in full by an insurance company. Full payment to our office remains your responsibility, regardless of how much your insurance does or does not pay. I am aware that Seton Family Dental Centre direct bills my insurance company as a courtesy to me and that in doing so, the dental office accepts no responsibility for any uncovered amounts, amounts over benefit maximums, limitations or plan restrictions, etc. I understand that the dental office collects my dental coverage information as a guideline only to assist me in maximizing my benefits and this does not hold them responsible for my dental account. Seton Family Dental Centre advises that I make myself aware of my dental plan and eligible coverage and that I ask my dental team about any and all procedures I am authorizing. Seton Family Dental Centre advises me to contact my plan administrator or insurance company for questions regarding eligible procedures and authorization of treatment. In addition, I am advised to make myself aware of all costs involved with my dental care. Seton Family Dental Centre advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan. Payment is due at the time of service. I am aware that if the dental office does not receive confirmation from my insurance for their exact payment, then Seton Family Dental Centre will estimate my portion at the time of visit. A statement of any unforeseen balance will be provided to me. I agree to pay all of these uncovered portions within 10 days from the date of statement or interest charges of 5% per month may be applied to my account. I agree to pay these interest charges if applied to my overdue account. I also understand that any uncovered procedures that may have been done at another dental office are my responsibility. IMPORTANT: Please be advised that complete oral examinations (new patient exams) & x-ray coverage will be denied by your insurance if you have had this procedure completed at another dental office within the time limitations on your specific plan. You are responsible for this payment then in our office should this not be an eligible benefit with your coverage. Financial Responsibility I agree to the financial responsibility for any amounts not covered by my dental insurance to be applied to credit card below: Credit Card (Circle one:) VISA MASTERCARD Card Number: Exp: Name as it appears on the card: Signature: Today s Date:
5 Seton Family Dental Centre Personal Information Consent Form Privacy Act Information We are committed to protecting the privacy of our patients personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, home/cell telephone numbers, and addresses. (Collectively referred to as Contact Information.) Contact information is collected and used for the following purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To process claims for payment or reimbursement from third party health benefit providers and insurance companies To send reminders to patients concerning the need for further dental examination or treatment To send patients informational material about our dental materials To follow up with treatment and/or customer services Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient s behalf. Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as Medical Information.) Patients Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients Medical Information is disclosed for the following purposes: To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient s behalf To other dentists and dental specialists where we are seeking a second opinion and the patient has consented to us obtaining the second opinion To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion To other health care professionals, such as physicians, if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment If we are ever considering selling all or part of our dental practice, qualified, potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest. Signature of Patient/Guardian Printed Name Date
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)
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
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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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STEPHEN C. SNITZER, D.D.S.,
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Patient 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
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 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 ( )
Yes 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,
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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
Patient 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,
PATIENT HEALTH HISTORY
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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
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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
REGISTRATION FORM / MEDICAl- DENTAL HISTOR. Telephone Number: _. Referred By: Family Members in the Practice: _. Preferred Tim e for Appointments:
REGISTRATION FORM / MEDICAl- DENTAL HISTOR Residence Address: ------------------------------------------------------- Telephone Number: Referred By: Family Members in the Practice: Preferred Tim e for
Tell Us About Your Child
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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
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 #:
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Patient Information. Spouse or Responsible Party Information. Insurance Information
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Child Dental Registration
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Kingsland 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
Pro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other
Highland 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
Upperman 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
MEDICAL 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
PATIENT 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
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
WELCOME PATIENT INFORMATION. Name Patient Prefers to be called Address. Home Address City State Zip Code How Long. Birth Date / / Month Day Year
14 North Hale Grantsville UT 84029 WELCOME Today s date: Thank you for entrusting your oral health care to our team of dental professionals. We are committed to serve you with the best in dental care while
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
3330 South Price Road, Suite D-110 Tempe, Arizona 85282 Phone: 480.345.2080 Fax: 480.345.2199 W E L C O M E ABOUT YOU (please print) Today s Date: Patient Name: DOB: Age: SS#: Mailing Address: City: State:
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
Welcome 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
Medical 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
Jennifer 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
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
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
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE Please print and complete this questionnaire prior to your first physical therapy appointment. The purpose of this questionnaire is to help us understand your health status.
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
Office Location: Media Glen Mills Havertown Date of Evaluation. Last Name, First, Address. City State Zip. Home Phone: ( ) -- Work Phone:( ) -- SS#
Pain Relief and Physical Therapy 203 E Baltimore Pike, Suite 2 101 W. Eagle Road, Suite 1 Media, PA 19063 Havertown, PA 19083 Phone: 610-565-0670 Phone: 610-789-9887 Fax: 610-565-7706 Fax: 610-789-9883
Chiropractic Health Dr. Art Vanderhoef
Patient Information Form Chiropractic Health Dr. Art Vanderhoef File # Name Address City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email Address How do you prefer to be contacted? Mail Home