New Patient Information
|
|
|
- Jeremy Glenn
- 5 years ago
- Views:
Transcription
1 Patient's Street Address: Home Phone: Cell Phone: of Birth: / / New Patient Information State: Name of Person Responsible for This Account: Address: Zip Code: Work Phone: SSN: Do You Have Dental Insurance: YES NO Policy Holder's Policy Holder's DOB: Policy Holder's SSN: Name of Insurance Company: Name of Employer Insurance is Through: Emergency Contact Information: Name and Relationship to Patient: Phone Number: Today's / / AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION TO FAMILY MEMBERS Please list any specific questions or areas of concern you have about your oral health: How long has it been since you were seen by a dentist? Whom may we thank for referring you to our office?
2 Oral Screening Consent Form Our practice continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. 35,000 new cases of oral cancer are diagnosed each year. The 5 year survival rate is only 50%. With early detection, you have a much better chance of surviving oral cancer. That is why we recommend anyone 15 years of age and older, be screened annually. Risk factors for developing oral cancer include: smoking, chewing tobacco, alcohol consumption, and some strains of Human Papillomavirus (HPV). HPV is an increasingly common virus with approximately 6 million new cases per year. We want to partner with you in beating cancer and keeping you healthy. In order to do that, we are now offering HPV screenings for the mouth and ViziLite Plus oral cancer screening that allows us to catch cancer at its earliest stages. Please Complete the Following Yes, please test me for cancer causing HPV ($165) Yes, please include the ViziLite Plus screening with my exam today ($50) No, I am declining these potentially lifesaving tests at this time. I prefer a visual exam only. Patient : Signature of Patient, Parent of Guardian:
3 Office Policies Please read this form carefully. Should you have any questions, our office coordinators will be delighted to help you. Please Check All Boxes Appointments & Deposits: At Dental Solutions we consider the appointment the confirmation. Although we may send you reminders, by setting the appointment we are making a commitment to block a portion of time specifically for you and making it unavailable for other patients. As a courtesy, please notify Dental Solutions if you cannot make your appointment at least 24 hours prior to the scheduled time. Missed or late cancelled appointments may be subject o a fee of $50 per hour scheduled. Appointments for treatment that require more than two (2) hours will require a deposit of 50% of the patient portion to secure the appointment. Dental Insurance: For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement on your behalf. Your insurance is a contract between you and your insurance company. Dental Solutions is NOT a part of that contract. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select services they will and will not cover. We are an amalgam (mercury) free office. If your insurance only pays for the alternate amalgam fee, then you are responsible for the non-covered difference in the fee. If your insurance carrier does not pay the estimated benefit in full, you will be immediately responsible for any remaining balance. If we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. Financial Policy: Full payment is due at the time of service. Forms of payment we accept: Cash Check o If a check is returned unpaid, there will be a $35.00 charge and checks will no longer be accepted. Credit Cards (Visa, Mastercard, Discover) Care Credit (10% Fee) Payment & Collections: Patient acknowledges and agrees that all accounts past 30 days shall bear a compounding interest rate of 1.5% per month. In the event that a patient does not pay for performed services, Dental Solutions, may place patient's account with a collection agency. Patient further agrees to pay reasonable collection fees.
4 General Consent Form I hereby authorize and direct the dentists of Dental Solutions and/or dental auxiliaries to perform dental treatment with the use of any necessary or advisable radiographs (x-rays) and/or any other diagnostic aids in order to complete a thorough diagnosis and treatment plan. In general terms, the dental procedure(s) can include but not be limited to: a. Comprehensive oral examination, x-rays, cleaning of the teeth, and application of topical fluoride. b. Application of plastic sealants to the grooves of teeth. c. Treatment of diseased or injured teeth with dental restorations (fillings). d. Placement of space maintainers and/or replacement of missing teeth with dental prosthesis. e. Treatment of diseased or injured oral tissues secondary to traumatic injuries and/or accidents and/or infections. f. Oral surgery, extractions (removal), root canal, crowns, bridges and orthodontic treatment are a few treatments that require additional consent forms. I understand that the doctor is not responsible for previous dental treatment. I understand that, in the course of treatment, this previously existing dentistry may need adjustments and/or replacement. I authorize the dentists of Dental Solutions, to forward a review of finds and/or any other dental information to the referring doctor (if such has been the referral source) or any other health care giver for his/her records, as well as any third parties such as insurance companies who may request information. I authorize Dental Solutions to take photographs, x-rays, and/or videos of my face, jaws, and teeth as a record of my care. I authorize Dental Solutions to use photos of a non-clinical nature for their website or social media with the following exceptions: I do not wish to have my first name show or released I do not wish to have my entire face shown I only agree to have my teeth shown without any identifying features I do not expect compensation, financial or otherwise, for the use of these photographs. Responsible Party: As the responsible party, in the case where my spouse and/or children are also patients at Dental Solutions, signing this Office Policies form will apply to them and their accounts as well. Signature of Responsible Party Print Name of Responsible Party
5 Dental Solutions ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES ("Acknowledgement") I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practices. Patient Name (Please Print) Patient Signature OR Signature of Personal Representative Authority of Personal Representative to Sign for Patient (check one): Parent Guardian Power of Attorney Other: Please Note: It is your right to refuse to sign this Acknowledgement. Dental Office Use Only I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: An emergency prevented us from obtaining acknowledgement. A communication barrier prevented us from obtaining acknowledgement. The individual was unwilling to sign. Other: Staff Member Signature
Family Dental Care of Gainesville, PLLC Dr. Matthew Bayne, DDS 112 N. Denton Street Gainesville, TX Offce phone:
Family Dental Care of Gainesville, PLLC Dr. Matthew Bayne, DDS 112 N. Denton Street Gainesville, TX 76240 Offce phone: 940-665-4211 FINANCIAL AGREEMENT Welcome to Family Dental Care of Gainesville! Thank
NEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
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
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
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 #: (
Address (if different from above):
Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
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 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
MOBILE PREMIER PEDIATRIC DENTISTRY Maureen T. Baldy, D.M.D.
MOBILE PREMIER PEDIATRIC DENTISTRY Maureen T. Baldy, D.M.D. 3920 Airport Blvd, Mobile, AL 36608 251-342-3323 www.mobilekidsdentist.com Welcome! We would like to welcome you to our practice. Our goal is
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
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)
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
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
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
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
Federal Employee Dental Options Guide for Lovelace FEHB Plan Members
Federal Employee Dental Options 2014 Guide for Lovelace FEHB Plan Members Option 1: Sandia Plan The Sandia Plan is the most economic dental plan option. Members obtain dental services from our ever expanding
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
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
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
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
CONSENT FOR DENTAL TREATMENT AND ACKNOWLEDGEMENT FOR RECEIPT OF INFORMATION
CONSENT FOR DENTAL TREATMENT AND ACKNOWLEDGEMENT FOR RECEIPT OF INFORMATION State law requires that we obtain consent for the contemplated dental treatment. What you are being asked to read and sign is
NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY
NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY Date: Patient Information Child s Full Name Age Sex (M) (F) Nickname (if any) Birth Date Whom may we thank for referring you General Information Mother/ Father
212 SE 12 th Street - Fort Lauderdale, FL Patient Information
Name Patient Information What is the reason for today s visit? How did you hear about our office?(person s name if any)_ Is there anything about your smile that you do not like? How long since your last
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
Patient Registration (Please fill out one per family)
Patient Registration (Please fill out one per family) Child s First and Last Name: Date of Birth: Child s Preferred Name: Gender: Male Female Child s Address: Child s City, Zip Code: Additional Children
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)
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:
Gentle Dentistry Stephanie M. Busch-Abbate, D.D.S., PLC. General Information
Gentle Dentistry Stephanie M. Busch-Abbate, D.D.S., PLC O: 269-381-3890; F: 269-381-9743 www.gentledentistrykzoo.com General Information Child s name: Nickname:Sex: (M) (F) First Middle Last DOB: SS# Is
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 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
Retiree Dental Open Enrollment
Retiree Dental Open Enrollment November 1 December 15, 2017 Open Enrollment Fact Sheet Delta Dental Information Sheet Delta Dental Enrollment Form Delta Dental Direct Debit Application Retiree Dental Plan
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:
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:
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
Home Sleep Test (HST) Instructions
Home Sleep Test (HST) Instructions 1. Your physician has ordered an unattended home sleep test (HST) to diagnose or rule out sleep apnea. This test cannot diagnose any other sleep disorders. 2. This device
Personal Blue Dental SM Personal Blue Dental Plus SM Individual dental plans from Blue Cross Blue Shield of Michigan
Personal Blue Dental SM Personal Blue Dental Plus SM Individual dental plans from Blue Cross Blue Shield of Michigan Sink your teeth into total health It may surprise you to know that the condition of
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
Dear Patients, We have good news to share with you!
Dear Patients, We have good news to share with you! It gives us great pleasure to introduce the Grand Marais Family Dentistry Benefits Plan. This in-house dental savings plan offers affordable care for
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
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print Referring Physician: Child s (Patient) Name: LAST FIRST MIDDLE Gender: Male Female Date of Birth:
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
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:
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
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
Natural Health Center
Natural Health Center 420 Yucca Lane - Turpin, OK 73950 Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340 Today s Date / / Application for Treatment Name: Birthdate: SS# Address:
Sandia Plan Join our Sandia Plan today and enjoy on-the-spot savings from 20% to 60% on more than 250 dental procedures like exams, cleanings,
Sandia Plan Join our Sandia Plan today and enjoy on-the-spot savings from 20% to 60% on more than 250 dental procedures like exams, cleanings, fillings, root canals, crowns, and even braces. The Sandia
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 #:(
Delta Dental of Oklahoma. Dental Program Options for Individuals & Families
Delta Dental of Oklahoma Dental Program Options for Individuals & Families Solutions for You & Your Family Option 1 Delta Dental Patient Direct 2 Option 2 Delta Dental PPO Choice Advantage 3 Option 3 Delta
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
Delta Dental of Wisconsin 2016 Open Enrollment Materials. For AFSCME Council 32
Delta Dental of Wisconsin 2016 Open Enrollment Materials For It s open enrollment time. Follow the steps to edit your current coverage or enroll in the plan. If you are currently enrolled and do not have
Brandon School Division Teachers. Dental Plan
Brandon School Division Teachers Dental Plan Eligibility Dental benefits are available to all regular full-time or part-time teachers signed to a Teacher General Contract, and to teachers on a Limited
Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY.
Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY. Form No. 005DPID(1/18) The Dental Plus of Idaho plan is a managed care dental policy and is underwritten by: Willamette Dental of Idaho, Inc.
Carter Physiotherapy, PLLC Patient Contact Information
Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip DOB Age Gender Marital Status Cell Phone Home Phone Email Employer Occupation Parent/Guardian/Spouse
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
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
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:_
CONDITIONS OF SERVICES RENDERED
CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate
Lincoln County School District
Lincoln County School District Delta Dental will be your new dental benefits provider effective July 1, 2016. Delta Dental has two networks of participating providers: Delta PPO & Delta Premier. Please
Child Dental Registration
Child Dental Registration Patient Information Patient Name DOB / / Male Female Address City State Zip School Patient Lives: With Both Parents With Mother With Father Other Parent/Guardian Information Parent/Guardian
Patient s Full Name Age Sex: (M) (F) Whom may we thank for referring you?
Date: / / Patient Information Patient s Full Name Age Sex: (M) (F) Nickname (if any) Birthdate: / / Whom may we thank for referring you? General Information Parent/Legal Guardian (full name) Birthdate:
A Dental Benefits Program For Individuals and Families Group #2525. HDS. A plan that puts a smile on your face.
A Dental Benefits Program For Individuals and Families Group #2525 HDS. A plan that puts a smile on your face. Your Dental Benefits The health of your teeth and gums directly affects your overall health.
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
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
MEMBERSHIP AGREEMENT: DESCRIPTION OF SERVICES AND DISCLOSURE FORM Plan Contract
The following is a description ( Description ) of the discount dental plan available to you and your family members through The CDI Group, Inc. ( CDI ). The Description completely describes the plan and
PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
SmileNet SM Dental Discount Program
SmileNet SM Dental Discount Program We want to catch you smiling. for Individuals and Families Effective April 1, 2005 Why Dental Care Should Be a Priority for You and Your Family Good oral health means
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,
2014 Rates. About Delta Dental networks BENEFITS OVERVIEW. Employee Only: $ Employee & Spouse: $ Employee & Child(ren): $83.
BENEFITS OVERVIEW Benefit Summary for: Denny s, Inc. Effective Date: January 1, 2014 Plan Option: HIGH PLAN Delta Dental PPO Dentacare M Delta Dental PPO & Premier Non- Participating Providers Part-Time
Dental Plan TABLE OF CONTENTS
Dental Plan TABLE OF CONTENTS INTRODUCTION... 2 ELIGIBILITY... 2 ELIGIBLE DEPENDENTS... 2 EFFECTIVE DATE OF COVERAGE... 2 BENEFITS... 3 BASIC SERVICES... 3 MAJOR SERVICES... 4 ORTHODONTIC SERVICES... 4
COLVIN AVENUE DENTAL. Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York WELCOME LETTER. Dear
WELCOME LETTER Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York 12206 518-459-7993 Dear Welcome to our dental practice. Our dedicated and experienced team has been providing quality and comfortable
General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
General Information: First Name: Middle Initial: Last Name: Suffix: Called Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: Marital Status:
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Your Ticket To A Great Smile!
Your Ticket To A Great Smile! Child s Information Date / / Child s Name Preferred Name (Last) (First) (Middle) Date of Birth / / Male Female Social Security# / / Child s Address Child s Home # / / City
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
PLAN OPTION 1. Network Select Plan. Out-of-Network % of R&C Fee **
Harvest Management Sub LLC. dba Holiday Retirement Dental Metropolitan Life Insurance Company Network: PDP Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions)
MetLife Dental Insurance Plan Summary. In-Network % of Negotiated Fee * % of R&C Fee 100% 100% 80% 80% 50% 50%
TriNet IV, Inc. Classic Option LA, MS, MT& TX Employees Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions) Type C: Major Restorative
2053 Sidewinder Dr. Welcome to Our Office! Park City, Utah 84060
Mountain Dentistry S. Scott Kimche DDS 2053 Sidewinder Dr. Welcome to Our Office! Park City, Utah 84060 (435) 645-8500 Welcome to our practice. Please take your time to fill out this form completely. The
In-Network 100% 80% 50% 40%
DriveTime Automotive Group, Inc. Dental Network: PDP Plus Standard Plan Coverage Type Type A: Preventive (cleanings, exams, X-rays, composite fillings ) Type B: Basic Restorative (extractions, endodontics,
Dental and Vision for Everyone
Dental and Vision for Everyone Dental and Vision Coverage in One Program* For Benefits Association, Inc. members including Individuals, Small Employers**, and Senior Citizens Dental Underwritten by: Delta
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
Individual/Family Dental Program
Individual/Family Dental Program Disclosure Form/Contract Provided by: All Aboard Benefits 800-462-2322 Ext. 1001 mike@allaboardbenefits.net www.allaboardbenefits.net Delta Dental Insurance Company provides
DENTAL DIAGNOSIS AND TREATMENT
OFFICE POLICIES EXPECTED PAYMENT In order to keep our fees as low as possible we ask that co payments be paid at the time of service. For your conveniene an estimate for dental care will be prepared prior
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 REGISTRATION
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
Manitoba Government Employees DENTAL PLAN
Manitoba Government Employees DENTAL PLAN January 2017 This information is a synopsis of the benefits provided under the Dental Plan. In the event of any difference between the terms of this synopsis and
plus DENTAL Willamette Dental of Idaho, Inc W. Emerald St., Suite 108, Boise, ID DENTAL INSURANCE Idaho
Summary of Exclusions Coverage does not include: Conscious sedation/general anesthesia Any condition resulting from military service or war Injuries sustained while practicing or competing in a professional
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
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
Dental Insurance. Eligibility
3.1 Group (Compulsory) Dental Insurance Eligible employees and their families, if applicable, are covered under the Brandon University Dental Plan as presented by the Manitoba Government Employees Association.
MetLife Dental Insurance Plan Summary
Northshore School District MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type Level 1 % of Negotiated 99% of R&C * % of Negotiated Level 2 99% of R&C * Type A: Preventive (cleanings,
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
Am I eligible to enroll in the Delta Dental of New Jersey Yale Graduate & Professional Student dental plan?
FAQs Dental Plan Am I eligible to enroll in the Delta Dental of New Jersey Yale Graduate & Professional Student dental plan? A: You must be a Yale University Graduate or Professional student enrolled at
WELCOME. 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
Healthy Smiles Dental Discount Plan
Healthy Smiles Dental Discount Plan Riverpoint Family Dentistry would like to provide excellent dental care to our local Albuquerque & Rio Rancho community. The costs of dental insurance premiums have
Stacey Dent, D.C., B.C.A.O Three Notch Rd. Unit 104 Hollywood, MD P: F: HarborBayChiropractic.
Stacey Dent, D.C., B.C.A.O. 23620 Three Notch Rd. Unit 104 Hollywood, MD 20636 P: 301-373-3731 F: 301-373-3970 HarborBayChiropractic.com Welcome to Harbor Bay Clinic of Chiropractic! (For any question
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive 256-766-0270 Father: DOB: SS#: Home Address: Home #: Work #: Cell #: Employed By: Address: Do you have dental insurance? Yes No
DENTAL FOR EVERYONE DIAMOND PLAN PPO & PREMIER SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS
DENTAL FOR EVERYONE DIAMOND PLAN PPO & PREMIER SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS DEDUCTIBLE Your dental plan features a deductible. This is an amount you must pay out of pocket before Benefits
PSYCHOLOGIST-PATIENT SERVICES
PSYCHOLOGIST-PATIENT SERVICES PSYCHOLOGICAL SERVICES Welcome to my practice. Because you will be putting a good deal of time and energy into therapy, you should choose a psychologist carefully. I strongly