PATIENT REGISTRATION
|
|
|
- Solomon Ball
- 5 years ago
- Views:
Transcription
1 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 Address Years as a Patient EMPLOYMENT INFORMATION: Business Name Business Phone ( ) Address Business Extension IF THE PATIENT IS A MINOR: Parent / Legal Custodian Name Home Phone ( ) Home Address School Attending EMERGENCY INFORMATION: Emergency Contact Relationship Address Phone Number ( ) PRIMARY INSURANCE INFORMATION: Insured s Name Relationship to Patient: o Self o Spouse o Parent Insured s SSN Insured s Birthdate Dental Insurance Carrier Address Phone ( ) Group or Local # Insured s Employer SECONDARY INSURANCE INFORMATION: Insured s Name Relationship to Patient: o Self o Spouse o Parent Insured s SSN Insured s Birthdate Dental Insurance Carrier Address Phone ( ) Group or Local # Insured s Employer
2 Thank you for taking the time to fill out this form completely. This information will enable us to provide you with a thorough evaluation and quality treatment. Your complete comfort and satisfaction are our primary concern. Are you under the care of a medical doctor for any illness or health problem (for the last two years)? o Yes o No Medical Doctor Name Phone ( ) Reason for Exam HEALTH HISTORY Do you have, or have you had, any of the following health conditions? Please provide information for all yes answers. 1. Congenital heart disease / Artificial heart valve o Yes o No 2. Bacterial / Infective endocarditis... o Yes o No 3. Heart murmur...o Yes o No 4. Heart surgery / Heart attack / Angina / Heart pacemaker...o Yes o No 5. High / low blood pressure...o Yes o No 6. Have you ever taken bone-enhancing drugs (Zometa, Aredia, Fosamax, Actonel, Boniva, Skelid, Bonefos, Ostac, Didronel) o Yes o No 7. Stroke...o Yes o No 8. Artificial joints: o Hip o Knee o Other ;if yes, when... o Yes o No 9. Fainting spells / Seizures / Epilepsy... o Yes o No 10. Diabetes...o Yes o No 11. Cancer; if yes, type and when...o Yes o No 12. Kidney trouble...o Yes o No 13. Lung disorders / Tuberculosis / Asthma / Emphysema / Etc....o Yes o No 14. Blood disorders such as Anemia... o Yes o No 15. Abnormal amount of bleeding... o Yes o No 16. Severe infection...o Yes o No 17. Hepatitis / Jaundice / Liver disease... o Yes o No 18. Cold sores...o Yes o No 19. Immune disorder (Lupus, HIV, ARC, AIDS)...o Yes o No 20. TMJ (temporal mandibular joint pain)... o Yes o No 21. If you are a woman, are you pregnant or breast feeding...o Yes o No 22. List of major surgeries or hospitalizations 23. Do you have any disease, condition, or handicap not listed above...o Yes o No 24. Are you taking medications, prescriptions, or over-the-counter drugs...o Yes o No If yes, please list 25. Do you have allergies or adverse side effects to local anesthetics (Lidocaine), latex, Penicillin, Codeine, or any other medications?...o Yes o No If yes, please list I, undersigned, being the patient, parent or guardian of the above minor patient, do state that the above information is to the best of my knowledge accurate, and I hereby consent to any necessary diagnostic procedures considered valuable by the doctor. I also understand upon completion of root canal therapy in this office, I will be referred to my general dentist for permanent restorations (crown, onlay, or filling) of the involved tooth. I acknowledge that I am under the care and supervision of my treating endodontist and not any other dentist. I further acknowledge that I am relying soley upon his knowledge, skill, and expertise. Print Patient s Name Birthdate For Minors, Print Legal Custodian / Guardian s Name Patient s Signature (guardian if minor) Today s Date Doctor s Review Date Patient Review Date Doctor s Review Date Patient Review Date
3 PATIENT SELF ASSESSMENT Today s Date 11/29/2017 Patient Name Please tell us the reason for your visit today Birthdate 1. Please check your current level of pain: no pain o 0 o 1 o 2 o 3 o 4 o 5 o 6 o 7 o 8 o 9 severe pain 2. If you are currently experiencing pain, or have had previous pain, with your tooth, please check the best description of the area: o Upper right portion of the mouth o Upper front teeth o Upper left portion of the mouth o Lower right portion of the mouth o Lower front teeth o Lower left portion of the mouth o Pain limited to one specific tooth o Pain from several teeth 3. Please check the word(s) that best describe your pain: o Sharp o Throbbing o Continuous o Burning o Dull o Aching o Intermittent o Itching o Other 4. How long have you experienced this pain? 5. Is the pain getting: o Better o Worse o Less frequent o More frequent o Staying the same 6. What makes your pain worse (check the word that best describes it): o Heat o Cold o Chewing o Other 7. What makes the pain better? 8. Has there been any swelling associated with the tooth: o Yes o No 9. Please list any dental work done in the area of pain within the past 6 months: Doctor s Notes
4 INFORMATION ABOUT ENDODONTIC TREATMENT (ROOT CANAL) We would like our patients to be informed about the various procedures involved in endodontic therapy and have their consent before starting treatment. Endodontic (root canal) therapy is performed in order to save a tooth which otherwise might need to be removed. This is accomplished by conservative root canal therapy, or when needed, endodontic surgery. The following discusses possible risks that may occur from endodontic treatment, and other treatment choices. RISKS Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics and injections. These complications include: swelling; sensitivity; bleeding; pain; infection; numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth; reaction to injections; changes in occlusion (biting); muscle cramps and spasms; temperomandibular (jaw) joint difficulty; loosening of teeth; referred pain to ear, neck and head; nausea; vomiting; allergic reactions; delayed healing and sinus complications. RISKS MORE SPECIFIC TO ENDODONTIC THERAPY These risks include the possibility of instruments broken within the root canals; perforations (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals, and cracked teeth. During treatment complications may be discovered which may make treatment impossible, or which may require dental surgery. These complications may include: blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), splits or fractures of the teeth. OTHER TREATMENT CHOICES These include no treatment, waiting for more definitive development of symptoms, having the tooth removed. In some circumstances the removed tooth may be replaced with an implant. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas. MEDICATIONS Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol or other drugs). Thus it is not advisable to operate any vehicle or hazardous device until recovered from their effects. CONSENT FOR TREATMENT I, the undersigned, being the patient (parent or guardian of aforementioned minor patient) consent to the performing of procedures and authorize the administration of such drugs and/or anesthetics as may be deemed necessary or advisable in the opinion of the Doctor. I further authorize them to do whatever they deem necessary or advisable as a result of unforeseen circumstances. I also understand that upon completion of root canal therapy in this office I will be directed to return to my general family dentist for a permanent restoration of the tooth involved, such as a post and/or crown, core build-up, composite, or amalgam filling. o Patient accepts recommended endodontic treatment plan o Patient declines recommended endodontic treatment plan Signature of patient (Parent or Guardian if Minor) Witness Date Date
5 PATIENT ACKNOWLEDGEMENT OF RECEIPT OF DENTAL MATERIALS FACT SHEET I,, have received a copy of the Dental Materials Fact Sheet. Print Name of Patient or Personal Representative: Personal Representative s Title: (e.g. Guardian, Estate Executor, Health Care Power of Attorney) Signature: Date: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES You May Refuse to Sign This Acknowledgment I,, have received a copy of this office s Notice of Privacy Practices. Print Name of Patient or Personal Representative: Personal Representative s Title: (e.g. Guardian, Estate Executor, Health Care Power of Attorney) Signature: Date: FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify):
6 We charge for root canal terapy by the tooth that is treated. Our fees are: Endodontic Consultation...$ Anterior Root Canal Retreatment... $1, Radiograph...$35.00 Insurance Patient s Down Payment... $ Anterior Root Canal Therapy...$ Premolar Root Canal Retreatment... $1, Insurance Patient s Down Payment...$ Insurance Patient s Down Payment... $ Premolar Root Canal Therapy...$1, Molar Root Canal Retreatment... $1, Insurance Patient s Down Payment...$ Insurance Patient s Down Payment... $ Molar Root Canal Therapy...$1, Post Removal... $ Insurance Patient s Down Payment...$ Composite Filling/Core Build-Up... $195.00
RESPONSIBLE PARTY INFORMATION:
Practice Limited To Endodontics 113A Tavern Road, Martinsburg, WV 25401 (304) 263-9191 Fax: (304) 263-9659 PATIENT HISTORY: M.I. Patient s Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender: Male or
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
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
Access 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)
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
ADULT PATIENT REGISTRATION FORM Name Social Security # Gender Preference M F Transgender (M to F) Transgender (F to M)
ADULT PATIENT REGISTRATION FORM Name Social Security # Gender Preference M F Transgender (M to F) Transgender (F to M) Date of Birth (MM/DD/YY) Primary Address City State ZIP PATIENT INFORMATION Alternate
PATIENT INFORMATION OFFICE PAYMENT POLICY PLEASE READ AND SIGN
PATIENT INFORMATION NAME: Last First Middle Initial Preferred Name SEX: Male Female STATUS: Single Married Child Other BIRTHDATE: -- -- SOCIAL SECURITY #: -- -- ADDRESS: Street City Cnty State ZIP PHONE
PATIENT 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
We 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
Dental 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
PATIENT 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
(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
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. (Print Patient s Name) (Signature-Parent/Legal
Patient Information. Date Primary General Dentist. Name: First Middle Last. Dental Insurance. Subscriber Name Relation to Patient Birth Date
Patient Information Date Primary General Dentist Name: First Middle Last Address City State Zip Code Email Home Phone Business Phone Cell Phone Birth Date Sex: M F Social Security # Patient Employed By
NEW 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:
Employment 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:
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
Welcome 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)
JOSEPH A SILVAGGIO, DMD KRISTIN M JABBAS, DMD BILAL CHAUDHRY, DMD
PLEASE ANSWER EACH AND EVERY QUESTION THE JOSEPH A SILVAGGIO, DMD KRISTIN M JABBAS, DMD BILAL CHAUDHRY, DMD Front and back sides of this form IT IS IMPORTANT TO INCLUDE all information we are requesting,
STEPHEN 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?
Married 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
PATIENT 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:
Registration. 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
Patient 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
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,
Endodontic Associates of Alaska 800 E. Dimond Blvd. Ste Anchorage, AK 99515
Date: Patient Information Name: Nickname Last First M.I. Male Female DOB: Child Single Married Widowed Separated Divorced Mailing Address: Street City State Zip Physical Address: Street City State Zip
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
Name: 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
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
Preferred 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:
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:
GENERAL 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
Welcome to Dr Jamie Italiane-DeCubellis s office
Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality
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
David 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
Insurance Information Release Form
Insurance Information Release Form Policy Holder s Information Policy Holder s Name Birthday Social Security Number Spouses Name Birthday Social Security Number Dependent's Name (last name if different
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 #:
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 ( )
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
Jason 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:
Patient 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
Dear 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
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 INFORMATION. Whom may we thank for referring you to our office?
PATIENT INFORMATION Patient s Name Male Female Last First Middle I prefer to be addressed as E-Mail address Address Street Apt # City State Zip Birthdate / / Social Sec# Driver Lic# Marital Status Home
Informed Consent. (Initials )
Informed Consent 1. EXAMINATIONS AND X-RAYS I understand that the initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan. I understand I am to have work
New Patient Information
New Patient Information Bloomfield Children s Dentistry 6405 Telegraph Road Bloomfield Hills, MI 48301 In order to get to know your family better, and to provide you with the best service, we ask that
PATIENT REGISTRATION 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!
Employer: Nickname: Male Female Work Phone: Date of Birth: Age: SSN: DENTAL HISTORY
ABOUT YOUR CHILD PARENT INFORMATION Child's Name: Mother's Name: Last Name First M.I. Employer: Nickname: Male Female Work Phone: of Birth: Age: SSN: Home Address: Father's Name: Employer: City State Zip
Kids Dental Care Adult Patient Registration
Kids Dental Care Adult Patient Registration To be updated every two years Patient's Name: DOB: SS# Sex: Male / Female Address: Apt/Unit/Floor: City: State: Zip Code: Home Phone #: ( ) - Cell Phone #: (
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:
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
Julia 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
Lake 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
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
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
PARENT INFORMATION ABOUT YOUR CHILD DENTAL INSURANCE INFORMATION DENTAL INSURANCE INFORMATION DENTAL HISTORY. Mother's Name: Child's Name:
Child's Name: Mother's Name: Last Name First M.I. Employer: Nickname: Male Female Work Phone: of Birth: Age: SSN: Email Address: Home Address: ABOUT YOUR CHILD PARENT INFORMATION Father's Name: Employer:
New Patient Information
Patient's Street Address: Home Phone: Cell Phone: of Birth: / / New Patient Information State: Name of Person Responsible for This Account: E-Mail Address: Zip Code: Work Phone: SSN: Do You Have Dental
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
REGISTRATION 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
AJ 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:
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
MEDICAL 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
APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC
APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC Patient Information (To be completed by the patient Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: Date: / / First Name:
Patient 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:
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
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
Greater Washington Endodontics. Signature Form for Statement of Privacy Practices
Greater Washington Endodontics (Formerly Drs. Levin, Leff, Pollock & Associates) Signature Form for Statement of Privacy Practices Office Locations: Falls Church Burke Arlington Reston 311 Park Ave. 8987
Sorina 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
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
DENTISTRY REVOLUTIONIZED
Narducci Dental Group, P.A. Welcomes You to Our Dental Family We at the Narducci Dental Group, P.A. and affiliated offices wish to take a moment to welcome you to your new Dental Home. Our philosophy is
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 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
White 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
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,
Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance
1 Today s Date: 2 (225) 664-2646 (225) 664-2640 (fax) 245 VETERANS BLVD. DENHAM SPRINGS, LA 70726 Who is Accompanying Your Child Today? Name: Relation: Do you have legal custody of this child? Yes No Tell
Emergency 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
Lake 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
PATIENT 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 _
DENTAL TREATMENT CONSENT FORM
Patient Name DENTAL TREATMENT CONSENT FORM Birthdate Please read and initial the items checked below. Then read and sign the section at the bottom of form. 1. WORK TO BE DONE I understand that I am having
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
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
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 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:
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
Patient 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:
PERSON 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
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
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 #:
General Dentistry Cosmetic Dentistry Endodontics Oral Surgery Orthodontics Periodontics DENTAL HISTORY. How may we help you today?
SmilesWest General Dentistry Cosmetic Dentistry Endodontics Oral Surgery Orthodontics Periodontics DENTAL HISTORY How may we help you today? Your current dental health is: Good Fair Poor Do you require
Today s Date: Date of Birth: Social Security #: MM/DD/YYYY. Name: Age: Last First MI (nickname) Address: Street & Apt # City State Zip Code
Please take a few minutes to fill out this form as complete as you can. If you have any questions we will be glad to assist you the better we communicate, the better we can care for you! We look forward
Welcome To Our Office
Welcome To Our Office Our practice is dedicated to providing technically excellent comprehensive dental care in a relaxed and caring environment. Our goal is to work with you in keeping your smile for
Welcome to Our Office!
Welcome to Our Office! We would like to take the time to Thank You for allowing us to take great care of you and provide you with excellent dental care. Please take a moment to tell us how you heard about
Creating 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
Kingwood Dental Specialists Oral Surgery ~ Endodontics ~ Periodontics
Oral Surgery ~ Endodontics ~ Periodontics NAME Referred to us by Parent/Guardian if minor of birth Single Married Minor (under 18) Address Home ph City State Zip Cell ph Male Female SS# Email Address Emergency
A 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:
GIVE KIDS A SMILE. Sincerely,
GIVE KIDS A SMILE MOBILE DENTAL PROGRAM Dear Parent or Guardian: Bethany s Give Kids a Smile program provides free dental care for children who cannot afford to get dental care on their own. Our dental
Patient Information:
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
Twohig Dentistry Dental and Oral Health Information
Twohig Dentistry Dental and Oral Health Information Patient s name: Date: Please describe any specific dental problem or discomfort you are having at this time: How long has it been present? If you have
Westlake Endodontics, P.A
Patient Information Welcome to Westlake Endodontics! We are pleased that you chose us and we look forward to providing you with the best endodontic care and service possible. Please start by filling out