Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
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- Ross Blair
- 5 years ago
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1 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 is needed upon which we can base recommendations for your dental health. Therefore, we will complete a thorough oral health and cosmetic dental examination during your initial appointment. Preventive dentistry is the most important service we have to offer you. We will show you how to control your own dental health and maintain your beautiful smile. Preventive examinations on a regularly scheduled basis will give you the maximum opportunity for long-term dental health. Good communication is essential to forming a satisfactory relationship. If you ever have a concern about any treatment, fee, or service, please feel free to discuss it immediately and openly with any of us. We would really appreciate this. We welcome your comments and suggestions, and want to do everything we can to make your visit a pleasant experience. Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you. Sincerely, Drs. Carol and Scott Lybrook
2 551 Kokopelli Blvd. Kokopelli Professional Plaza Fruita, CO WELCOME : Legal Name: Male Female I prefer to be called Married Single Divorced Widowed Separated Birth date: Age: Home Address: City: Zip: Home#: Work#: Cell#: Social Security# Driver s License# May we confirm your appointments using your address? Yes No Employer: How long at job Address: Whom may we thank for referring you? Parent or Spouse Information His/Her Name: Home #: Work#: Soc. Sec. #: Birthdate: Employer: Person Responsible for Account: Home#: Work#: Cell #: Soc. Sec. # Drivers License#: Dental History Previous/Present Dentist: Last Visit Why have you come to the dentist today? Are you currently in pain? Yes No Have you ever had a serious/difficult problem associated with any previous dental work? Yes No Do you or have you ever-experienced pain/discomfort in your jaw joint (TMJ, TMD)? Yes No Your current Dental Health is: Good Fair Poor Do you like your smile? Yes No Do your gums ever bleed? Yes No How many times a week do you floss: How many times a day do you brush? Type of bristles? Hard Medium Soft
3 Medical History Do you have a personal Physician? Yes No Physician s Name: Phone# Last Visit : In case of emergency, whom should we contact? His/Her Name? Relationship: Home#: Work#: Cell#: Your current physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Are you taking any prescription/over the counter drugs? Yes No Please list each one: For Women only: Are you taking birth control pills? Yes No Are you pregnant? Yes No Week #: Are you nursing? Yes No Please list any medical condition(s) you now have or have ever had: Are you allergic to any of the following: Aspirin Erythromycin Codeine Latex Gloves Penicillin Jewelry/Metal Dental Anesthetics Tetracycline Other (explain) Please list any drugs you are allergic to: Please CIRCLE all of the medical problems you currently have or have ever had: Artificial Joints Abnormal Bleeding Fever Blisters/Herpes Shingles Blood Transfusions Anemia Glaucoma Sinus Problems Cong. Heart Defect Asthma Heart Attack Stroke Heart Murmur Arthritis Heart Trouble Ulcers Heart Pacemaker Cancer Hemophilia Venereal Disease Mitral Valve Prolapse Chemotherapy High/Low Blood Pressure Diabetes Rheumatic Fever Colitis Hospitalized for any reason Gluten Intolerance Heart Surgery Difficulty Breathing Kidney Problems Osteoporosis Hepatitis Drug/Alcohol Abuse Psychiatric Problems Thyroid HIV/AIDS Emphysema Radiation Treatment Acid Reflux Tuberculosis (TB) Epilepsy Severe/Frequent Headaches I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I any need during diagnosis and treatment with my informed consent. SIGNATURE: *PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. Doctor s Comments: I verbally reviewed the medical/dental information above with the patient named herein. Comments Signature
4 GENERAL CONSENT Thank you for choosing our office for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the benefits of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to offset the benefits of treatment, but should be considered when making treatment decisions. Benefits of dental treatment can include: relief of pain, the ability to chew properly, and the confidence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually any dental procedure, including: 1. Drug or chemical reaction. Dental materials and medications may trigger 2. allergic or sensitivity reactions. 3. Long-term numbness (paresthesia). Local anesthetic, or is administration, 4. while almost always adequate to allow comfortable care, can result in 5. transient, or in rare instances, permanent numbness. 6. Muscle or joint tenderness. Holding one s mouth open can result in 7. muscle or Jaw joint tenderness, or in a predisposed patient, precipitate a 8. TMJ disorder. 9. Sensitivity in teeth or gums, infection or bleeding. 10. Swallowing or inhaling small objects. While we follow procedural guidelines that most often lead to a clinical success, just like in any other pursuit in health care, not everything turns out the way it is planned. We will do our best to assure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you. I have read and understand the statement on this page: Patient s Signature Parent s Signature (if minor patient) 551 Kokopelli Blvd. Kokopelli Professional Plaza Fruita, CO
5 Lybrook Dental Center Financial Policy We strongly feel that all patients deserve from us the finest dental care that we can provide. You will benefit from the high standards we have set for delivering the utmost quality of dental treatment available. We also feel that when financial arrangements are discussed and agreed upon, everyone benefits. Accordingly, we have prepared this information to acquaint you with our financial policy. PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. Please indicate below the method of payment that you will use to pay for the dental treatment. Payment Options: You can choose from: Cash or Check MasterCard, American Express, Discover Card or Visa Extended Payment Options: NO INTEREST Payment Plan from Care Credit (6 months) *Allows you to make payments over time with NO INTEREST, if paid on time and in full *Convenient, low monthly payment *No annual fees or pre-payment penalties Dental Insurance: Our office will do everything possible make the most of your dental insurance benefit. We do accept insurance benefits as partial payment for treatment along with your payment of the ESTIMATED patient portion cost. You are responsible for ALL fees and charges for our account. All insurance plans are different and may have limitations. These may include but are not limited to waiting periods, missing tooth clause, downgrade on services, exceptions and limitations of your specific plan for which we cannot be held responsible. Any insurance portion that has not been paid after 90 days will be billed to the patient. Dental Insurance Information: Employee/Policy Holder Name: DOB: Employer: Group Number: Primary Dental Insurance Carrier: ID Number: Insurance Carrier Phone Number: Please let us know if you have any questions or concerns. We are here to help you in any way we can. I have read the Lybrook Dental Center Financial Policy and I understand and agree to this policy. Patient, Parent or Guardian Signature
6 Lybrook Dental Center Missed Appointment Policy At Lybrook Dental Center, we are committed to providing all of our patients with exceptional care. When you have an appointment in our office, that time has been reserved exclusively for you! When a patient cancels without giving enough notice or fails to come for a reserved appointment it prevents another patient from being seen who is in need of dental care. Unforeseen events sometimes require a change of appointment. If you need to cancel or reschedule an appointment, we respectfully request notification of at least 48 hours in advance to avoid a charge. If you fail to arrive for your appointment and have not notified us 48 hours in advance, your account may be assessed a Missed Appointment Fee of $50.00 PER HOUR of reserved time. An appointment is considered missed/broken for one or more of the following reasons: 1. Failure to show up for a reserved appointment 2. Cancelling a reserved appointment without 48 hours notice 3. Showing up more than 15 minutes late for a reserved appointment I have read the Lybrook Dental Center Missed Appointment Policy and I understand and agree to this policy. Patient, Parent or Guardian Signature
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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:
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 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
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
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
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 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
Julia A. Hallisy, D.D.S., Inc.
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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 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
DENTAL 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:
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
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Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
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New Patient Information
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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 Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
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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
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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:
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
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
(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
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
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
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 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
Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
Home Address: Home Telephone: CHILD 1 First Name: Last Name: School: Age: Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION PATIENT INFORMATION Birthday: / / Sex:
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:
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
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
WELCOME. About You. Dental Insurance. Responsible Party s Information. Emergency Contact. Pharmacy Information
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Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
Patient Registration (complete form must be filled to process insurance claim) Patient Information First Name: Last Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Would you
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
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EMERGENCY INFORMATION Person to Contact: Relationship: Phone: Address:
WELCOME. We are a general (family) and cosmetic dental practice. The benefits of a healthy, beautiful smile are immeasurable, and our goal is to provide you with knowledge and options which allow you to
We Would Like to Get to Know You Better!
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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:
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:
Describe the pain and it s location:
WELCOME TO ZIVKOVIC CHIROPRACTIC CENTER DATE: Please print clearly and fill in completely. ABOUT YOU: Patient Name:_ What do you prefer to be called:_ SS# Street Address City State Zip Date of Birth: Age:
Medical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
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
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
Address (if different from above):
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FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
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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
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 #: (
PAUL T. OLENYN D.D.S.
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Welcome 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
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
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
White House Dental 347 West Idaho Avenue Ontario, Oregon (541) whitehousedental.net
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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:_
ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!!
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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 INFORMATION---- Patient s Full Name Preferred Name DOB Age Sex. School Grade. Residence Address. City State Zip Home Phone #
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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
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
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
Insurance Information
Smile by Design Windsor Adult Patient Registration Patient s Name: DOB: / / SS#: - - Sex: Male / Female Address: Apt/Unit/Floor: City: State: Zip: Home Phone#: ( ) - Cell Phone #: ( ) - Work Phone #:(
Fairfax Oral and Maxillofacial Surgery
Fairfax Oral and Maxillofacial Surgery Patient information: Today s Date Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Sex: Male Female Birth Date Age Soc. Sec. # E-mail Street Apt. City State Zip
NAME: 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
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 #:
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
If yes, please explain: Yes. If yes, please explain: Yes
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
Welcome to the office of
Welcome to the office of Date: 8340 Cleveland Avenue N. Canton, Ohio 44720 330.494.6305 PERSONAL INFORMATION (Please Print Legibly) Last Name: First Name: _ Middle Initial: _ SS #: _ I would prefer to
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:
Address, 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
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
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
Get Acquainted Questionnaire Tell Us About Your Child!
Get Acquainted Questionnaire Tell Us About Your Child! Today s Date Child s First Name Child s Last Name Nickname M F Child s Age Child s Date of Birth / / Residence Address City State Zip Residence Phone
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
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
Tell 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
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!
Patient Registration Form
Patient Registration Form Patient Information Date Name: I Prefer to be called: Address: City: State: Zip: Phone ( ) Work Phone ( ) Cell Phone ( ) The best time to contact me is: A.M. P.M. on my Home phone
Welcome to our Office!
Welcome to our Office! Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don t hesitate to ask one of our qualified team members. It is our pleasure