I Consent! Zombie Teeth
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- Buck Randall
- 5 years ago
- Views:
Transcription
1 I Consent! Zombie Teeth
2
3 Thanks, Partner! Cowboy Slim
4 Use it, or lose it! Hallie Tosis
5 1. Are you experiencing pain or discomfort?...y N 2. Are you in good health?...y N 3. Has there been a change in your general health within the past year?...y N 4. Are you under the care of a physician?...y N If so, what condition is being treated? Physician s name: Phone # Address: 5. List all previous hospitalizations, serious illnesses, and significant surgeries 6. List all countries visited in the past 21 days other than the United States 7. Have you experienced any cold, flu or viral type symptoms in past 21 days? Do you have or have you had any of the following diseases or problems? Please circle: AIDS/HIV Positive Cortisone Medicine Hepatitis A (Infectious) Rheumatism Allergies or Hives Cough Hepatitis B (Serum) Scarlet Fever Anemia Diabetes High/Low Blood Pressure Sickle Cell Disease/Traits Angina Pectoris Emphysema Kidney Trouble Sinus Trouble Arthritis Epilepsy/Seizures Latex Stroke Artificial Joint Fainting/Dizzy Spells Liver Disease STD or VD (Syphilis, Gonorrhea) Artificial Heart Valve Glaucoma Metals Thyroid Disease Asthma Hay Fever Mitral Valve Prolapse Tuberculosis Blood Transfusion Heart Attack/Disease Nervousness Ulcers/Colitis Bruise Easily Heart Failure Pain in Jaw Joints Yellow Jaundice Please answer each & every question. Chemotherapy (Cancer, Leukemia) Heart Murmur Plastics X-Ray or Cobalt Treatment Cold Sores/Fever Blisters Heart Pacemaker Psychiatric Treatment Congenital Heart Defects/Lesions Heart Surgery Rheumatic Fever 8. Do you have a disease, condition, or problem not listed above? Y N If yes, please explain 9. Are you allergic or have you reacted adversely to any drugs or medicines.y N If so, which drugs? Aspirin Demerol Nembutal/Seconal Penicillin Scopolamine Valium Codeine Erythromycin Nitrous Oxide Percodan Sleeping Pills Darvon Local Anesthetic Lidocaine or Marcaine Other Antibiotics Tetracycline 10. Are you taking any drug, medicine or herbal supplement Y N If so, what: 11. Have you had previous skin reactions to jewelry or know of an allergy to any metal?...y N 12. Have you had any serious trouble associated with any previous dental treatment? Y N 13. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?...y N 14. Is there anything about your smile you don t like such as discolored teeth, crooked teeth, unsightly silver fillings, etc.?...y N 15. Our doctors are accomplished cosmetic dentists. Would you like current information on smile improvement procedures they perform, such as bleaching, porcelain veneers, - and tooth colored restorations?..y N 16. FOR WOMEN ONLY: ARE YOU PREGNANT? Y N If yes, what month Are you taking birth control pill?.y N Miss Pearly White, RDH
6 CONSENT: the undersigned hereby authorizes Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient!s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with (Name of Patient) and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. PATIENT DATE WITNESS PARENT OR RESPONSIBLE PARTY RELATIONSHIP TO PATIENT Address: Phone #: !! 6Day Dental & Orthodontics
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9 No Posers! Biggie Smiles MODEL RELEASE I,, hereby authorize 6 Day Dental & Orthodontics to use photographs and videos of me (and/or my minor child ) and authorize 6 Day to use and publish the images herein described in print and electronic form for the purpose of publicity, illustration, commercial art, advertising, publishing (including publishing in electronic form or internet websites),for any product or service. I further waive any and all rights to review or approve any uses of the images, I have read and fully understand the terms of this release. Signed Date I am the parent or legal guardian of the above mentioned minor and have the legal right and authority to execute the above release on behalf of the minor. Signed Date
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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:
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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, could have
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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
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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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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
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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 ( )
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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
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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:
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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
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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
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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 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
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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 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 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 informationPATIENT INFORMATION GUARDIAN EMERGENCY CONTACT FINANCIAL RESPONSIBILITY METHOD OF PAYMENT
PATIENT INFORMATION Name Birthdate S.S.# HOME ADDRESS CITY STATE ZIP EMPLOYER OCCUPATION Sex: M F Marital Status: S M D W(IF MARRIED) SPOUSE S NAME SPOUSE S CONTACT NUMBER WK CELL GUARDIAN FINANCIAL RESPONSIBILITY
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 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
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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 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 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 informationREGISTRATION FORM PATIENT INFORMATION. Patient s last name: First: Middle: Marital status: Occupation: Employer: Employer phone #: Physician name:
REGISTRATION FORM PATIENT INFORMATION Patient s last name: First: Middle: Marital status: Address (write below): City: State: Zip code: Birth date: Age: Sex: Ú M Ú F Social Security #: Home phone #: Cell
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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
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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 informationWelcome to Our Practice!
Dr. Jason Carper, D.D.S ~ Dr. Chasity Carper, D.D.S. Welcome to Our Practice! We are pleased that you have chosen us as your dental care providers! We feel quite confident that you will find our staff
More information5205 Leesburg Pike #1406 Falls Church, VA O: (703) F: (703)
Dear Patient: We have prepared this letter to help you better understand the complexities of dental insurance; we realize how confusing it can be. To begin, we would like to highlight a misconception;
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
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Patient Information: First Name: Last Name: Middle Initial: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Sex: Female Male Marital Status: Married Single Divorced Separated Widowed Birth
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The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
More informationTODAY S DATE FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? SOCIAL SECURITY #
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
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 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 informationPreferred Name. Date of Birth Male Female Married Single Minor/Other. Home Address Street and Apt # City, State Zip Code. Home# Work# Cell/Other#
PATIENT AND RESPONSIBLE PARTY INFORMATION Name Last First M Preferred Name Date of Birth Male Female Married Single Minor/Other Home Address Street and Apt # City, State Zip Code Home# Work# Cell/Other#
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 information3. Are you now, or have you been in the past year, under the care of a physician?
Medical History Patient Name Birth Date ID Number 1. Do you have any of the following diseases or problems? Today s Date a. Active Tuberculosis b. Persistent cough greater than 3 weeks in duration c. Cough
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
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Account # PATIENT REGISTRATION PATIENT INFORMATION: Name M.I. Sex: o Male o Female Home Address Social Security # Birthdate Age Home Phone ( ) Mobile Phone ( ) Name of General Dentist E-Mail Address Years
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 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 informationWELCOME. About You. Dental Insurance. Responsible Party s Information. Emergency Contact. Pharmacy Information
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we ll be glad to help you. We look forward to working
More informationPLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:
DATE OF HEALTH HISTORY UPDATE: THIS IS A HEALTH HISTORY UPDATE. PLEASE INDICATE ANYTHING REGARDING YOUR HEALTH (MEDICAL AND DENTAL) THAT HAS CHANGED SINCE YOUR LAST VISIT TO OUR OFFICE. THANK YOU. WHAT
More informationCl Single Married Divorced Q Widowed Q Long-Term Partner
PATIENT REGISTRATION Today's Date_ Patient's Name Spouse/Parent Name_ Address City_ State Zip. Email Address Telephone - Home_ Cell Work Social Security#, Birth Date Cl Single Married Divorced Q Widowed
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 informationNAME: last first middle Mr. Mrs. Ms. Dr. city state zip Single Married Divorced Widowed Separated
WELCOME! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out these forms completely. The better we communicate, the
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