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1 Whitening Health History Form Name Sex Date of Birth / / Address City State Zip Home Telephone Family Physician General Dentist Employer Business Telephone In Emergency, Contact Telephone Telephone Telephone Occupation Your Dental History - Please indicate if any of the following items apply to you Do you have limited mouth opening (TMJ/TMD)? Do you have sensitivity to sweet/sour liquids or foods? Have you ever had a root canal? Do you have any missing teeth(besides wisdom teeth)? Do you gums bled when brushing and flossing? Do you have any sores in your mouth? Are your teeth discolored due to trauma, endodontics or a result of a antibiotics? Do you use any tobacco products? Do you have fixed orthodontic appliances now? Do you have any cracked teeth? Do you have any fillings in your front teeth? Do you drink: (circle): Tea, Coffee, Dark Soft Drinks, Red Wine Have you had orthodontic work (braces)? Do you gave teeth with extensive wear? Do you have receded gums? Braces removed in the last 4 week period? Date of your last dental exam/visit: / /, or circle the approximate time period since your last dental visit: 0-3 months 4-6 months 7-12 months 12 months or longer Rate (circle) your dental anxiety level: High Average Low None Rate (circle) your thermal sensitivity of your teeth to hot or cold: High Average Low None Have you used any teeth whitening products in the past? (circle) Yes/No If yes, what product and what was the result? Please list any current dental needs that you are aware of:
2 For Office Use Only PD T/SA SNC NSHC Cust. Number Source Code YOUR MEDICAL HISTORY Please indicate if any of the following items apply to you Are you sensitive to light? Do you sunburn easily? Are you pregnant? Please check the corresponding box if you are allergic, or had reactions to the following: Iodine Sulfa Drugs Aspirin/Advil/Tylenol Local Anaesthetics Sedatives Latex Rubber Penicillin or any other Antibiotics Any metals (Nickel, Mercury, etc.) Other Please check if being treated for or have been treated for any of the following Kidney Disease Respiratory Problems Joint Replacement Diabetes Cardiovascular Disease Frequently Tired Stroke Hepatitis Glaucoma High Blood Pressure Liver Disease AIDS/HIV Blood Clots Leukemia Fever Blisters Heart Trouble/Attack Artificial Heart Valves Heart Murmur Congenital Heart Disease Mitral Valve Prolapse Lung Disorders Asthma Hayfever Allergies Tuberculosis Tumors/Growths Canker Sores Blood Disorders Radiation Therapy Swollen Ankles Rheumatic Fever Stomach Ulcers Thyroid Problem Stomach Problems Venereal Disease Fainting/Seizures Herpes Recent Weight Loss History of Bulimia or Anorexia Drug / Alcohol Dependancy Currently/Have Taken Fen/Phen, Redux &/pr Other Pondium
3 Please circle the following answers that apply: Are you taking any medication/s? If Yes, list them Rate your present health status: Excellent Good Fair Poor List your major operations Anything else we should know about your health? I attest that the above Dental/Medical Health History information I have provided is true and correct: Patient/Parent or Legal Guardian Signature Date / / Dentist Signature Date / / IMPORTANT INFORMATION AND TERMS AND CONDITIONS APPLICABLE TO YOUR ZOOM! WHITENING PROCEDURE 1. Background We provide this information to give you insight into professional teeth whitening with the Zoom! Whitening System. Your cooperation and understanding of this material is necessary as we strive to achieve the best results for you. The safety of professional teeth whitening in general is very high, and the Zoom! Whitening system is no exception. Like all professional health care, though, there are limitations and risks (which will be discussed below), and absolute success is variable and cannot be guaranteed. 2. This Appointment is Limited To Teeth Whitening Today s visit consists of an exam, which pertains only to elective cosmetic tooth whitening. As a result, you understand that you presently may have a dental condition or health condition that goes undetected during your Zoom! Whitening visit, but which may be detectable during a comprehensive dental examination. If any dental issues are noted the Dentist will inform you. We insist you continue to see a General Dentist for Dental Health issues (I.e.; X-rays, cleanings, fillings, comprehensive exam, periodontal assessment, oral cancer screening, charting of the teeth). If you do not have a Dentist the attending Dentist can refer you to one. 3. Candidates For Zoom! Whitening Professional Teeth Whitening Eligibility for treatment is determined through information gathered during the consultation and screening. While many individuals will qualify for treatment, not all people are deemed candidates for the procedure. If this situation occurs, the doctor will discuss his/ her findings with you, perhaps along with certain other possible treatments or options as appropriate. 4. Expectations Upon Completion Of the Zoom! Whitening Professional Whitening Significant whitening can be achieved in many cases, but there is no definite way to predict how light your teeth will get. Candidates with yellow or yellow-brown teeth tend to whiten better or quicker than people with gray or gray-brown teeth. Teeth discolored by antibiotics, decalcification (white spots), root canal therapy, or trauma do not always respond as quickly or predictably, and may require additional treatment. On the other hand, if your teeth are already a light shade of white, for example a shade of Al-Bl or offscale on the Vita-Shade guide, your additional whitening results could be minimal. The level of whiteness varies with each individual; therefore, you may or may not achieve a higher degree of whiteness. During the consultation, you may be shown before/after pictures of previous clients so that you may have an overall perspective on the kind of results we typically can achieve. The dentist may also provide an assessment as to the level of whiteness you may achieve. If you have questions regarding this issue, please discuss them with the dentist prior to signing this form and proceeding with the Zoom! Whitening procedure. 5. Maintenance It may appear that there is a slight change in the shade of your teeth within the first hours. This is due to the reformation of a saliva coating. Also, through the normal staining process of day-to-day eating and drinking, you may experience a slight regression of shade. This will depend on the frequency of your use of tobacco products, coffee, tea, red wine, and other staining foods/drinks. This can generally be managed by a maintenance program at home. We recommend the use of Zoom! Whitening Toothpaste applied with the Zoom! Whitening Sonicare Toothbrush twice daily, followed by rinsing with the Zoom! Whitening Mouthrinse. The Zoom! Whitening gum can be utilized between meals or when brushing is not an option as part of the total maintenance program.
4 6. Alternative Treatment Options While we feel that Zoom! Whitening is by far the fastest, most effective means (both in terms of results and costs) for most people to whiten their teeth, please take note that there are other options available to you for whitening teeth. Among these options are: a) porcelain crowns b) porcelain veneers c) composite bonding veneers d) gel/tray systems (for use at home) e) other in-office procedures (using different light sources and chemicals) If you have questions regarding the other treatment alternatives, please ask the dentist or consult manager. 7. Potential Risks/Problems All forms of health treatment, including teeth whitening, have some risks and limitations. Complications that can occur in professional teeth whitening are generally infrequent, and are usually minor in nature. Please read the following information. If you have any questions about these potential risks/problems, please ask us before signing this consent form. a) Tooth Sensitivity - During the whitening process some patients may experience tooth sensitivity. This sensitivity is usually mild if your teeth are not normally sensitive. If your teeth are normally sensitive, please inform us before treatment so that we can make certain adjustments designed to reduce the risk of sensitivity. We cannot eliminate this risk. In some cases, we may suggest taking a mild analgesic before beginning the procedure. Please let us know if you experience any discomfort during the procedure. If your teeth become, or stay sensitive following the procedure, a mild analgesic (such as Tylenol or Advil) will usually be effective in helping you feel comfortable. This sensitivity generally goes away in hours. If it persists for more than 24 hours please contact our Zoom! Whitening Dentist. b) Gum and Soft Tissue Irritation - Temporary inflammation of the gums and other soft tissues of the mouth can occur during the procedure. This is generally the result of the whitening gel coming in contact with these tissues. Protective materials are placed in the mouth to prevent this, but despite our efforts, it can still sometimes occur. Stretching and/or irritation of the lips can also occur because of the use of the cheek retractor. If it does, the stretching and/ or irritation is generally short in duration (less than two hours), and is very mild (most patients never feel it). If it is felt, rinsing with warm salt water can relieve it. If discomfort persists for more than 24 hours please contact our Zoom! Whitening Dentist. c) Fillings and Other Dental Restorations - Tooth colored fillings (composites), composite veneers/bondings, porcelain crowns, and/or porcelain veneers will not whiten at all or evenly with your natural teeth during this procedure. We may however be able to remove certain stains (tobacco) from the surface of these restorations. All dental restorations that show when you smile may need to be replaced at your expense. Please be sure to discuss this with the dentist prior to beginning treatment. d) Decalcified, Traumatized, antibiotic discoloration - Teeth discolored by antibiotics, decalcification (white spots) root canal therapy, or trauma do not always respond predictably, and may require additional treatment other than whitening 8. Your Treatment Responsibilities a) Follow All Directions -Please take time to read all written instructions and listen carefully to all oral directions. You are welcome and encouraged to ask us any questions you may have. b) Communication- If you do not understand something communicated to you during the consultation, the exam, in any printed material given to you, and/or before or after the procedure, please feel free to ask us. 9. Confidentiality and Use and Disclosure of Information You understand that information obtained in this form will be treated as privileged and confidential and will not be released or revealed to any third party (other than for treatment, payment, or health care operations purposes) without your authorization, as described below. Your signature below indicates your authorization for the dentist and the dentist s staff to release to Zoom! Whitening, Inc., and for Zoom! Whitening, Inc. to use, reproduce, and publish photographic or computer illustrations of your teeth/mouth for educational or marketing purposes, and you waive all claims against any party based on the usage of the images, including, but not limited to, claims that the use of the image defames you or constitutes an infringement of your rights to privacy, or any other right you may enjoy. Your signature below also indicates your authorization for the dentist and the dentist s staff to disclose to any employee of Zoom! Whit-
5 ening, Inc. the information provided on this form and information related to the results of your Zoom! Whitening procedure to enable Zoom! Whitening, Inc. to: (i) send marketing and promotional materials to you in the future concerning the dentist s services, the Zoom! Whitening procedure, Zoom! Whitening products, and other related matters; (ii) conduct quality control surveys; and (iii) compile a research data base and conduct research regarding the safety, efficacy, quality, outcomes and cost effectiveness of Zoom! Whitening s tooth whitening light and gel process, or any component thereof. The information disclosed to Zoom! Whitening, Inc. may be subject to redisclosure by Zoom! Whitening, Inc. and may not be considered protected health information that is subject to federal privacy protections. It is not mandatory that you sign this paragraph 9, and you agree that if you choose to sign this paragraph 9, you have done so knowingly and voluntarily. Your authorization, as it relates to marketing and quality control, will remain in effect until the date or event you specify below. If no date or event is specified below, your authorization will remain in effect until you revoke your authorization. The expiration date or event of your authorization, as it relates to research, is none, and the research authorization will remain in effect indefinitely. You may revoke this paragraph 9 authorization, in whole or in part, at any time by providing a written notice of revocation to the dentist. Signature: Date Expiration Date/Event for Marketing and Quality Control Authorization AUTHORIZATION AND RELEASE The information that I have provided on this form is accurate and complete to the best of my knowledge, information and belief. I certify that I have thoroughly read and understand the above information. I have had the opportunity to investigate the Zoom! Whitening procedure and I have had all of my questions answered to my satisfaction. Furthermore, the above questions have been accurately answered. With this understanding, I authorize the Zoom! Whitening affiliated dentist to perform the Zoom! Whitening procedure on me. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Signature of Client/Parent or Legal Guardian Date / / How did you hear about Zoom! Whitening? TV Radio Newspaper Mail Magazine Website Friend Other Additional Information: Signature of Dentist Date / / Provide a signed copy of this informed consent form to the patient
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
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
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
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 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 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 ( )
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
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
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
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 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:
Julia A. Hallisy, D.D.S., Inc.
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Prosthodontics and Implant Surgery
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Welcome to South 40 Dental! Tell Us About Yourself
Welcome to South 40 Dental! Tell Us About Yourself Name: Last First MI Title Preferred Name: Male Female Parent/Guardian Name if Under 18 Years Old: Address: City Prov. Postal Code Date of Birth (day)
Medical Health Information (continued):
Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present
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
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
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:
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
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:
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
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,
NEW Adult Patient Information
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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
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
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
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
KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
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)
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?
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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
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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
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
Jason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology
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(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
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
Patient Name: D.O.B. Who may we thank for recommending us: Name of Dentist: Date of last visit:
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Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
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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 INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
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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:
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:
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Dental Patient Survey
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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:
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PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
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
At any time you can schedule a free thirty minute consultation with Dr. Rabile to discuss your smile.
Appointment Process We love to make you smile! We are always welcoming new patients to our office in the heart of Las Colinas. Whether you're looking for cosmetic dentist to help improve your smile, or
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
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
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
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
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
ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!!
BILL ANDERSON DDS, AUSTIN HOFFNER DDS 1401 East Sandusky St. Findlay Ohio 419-424-5850 ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!! Thank you for choosing our office! We strive to deliver high quality
Caring for your Dentures
DENTURES SERIES Caring for your Dentures It s important that your dentures, like natural teeth, be kept free from plaque and tartar. This prevents permanent staining and bad breath. Use a denture brush
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:
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Responsible Party Address City State Sex M F Age Birthdate Married Widowed Single Minor Separated
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
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:
Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.
(847)392-4422 afgd 1307@gmail.com Dental History What is the reason for your visit today? Date of Last Dental Visit: Last Dental Cleaning Last set of X-rays What was done at your last dental visit? Q Cleaning
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
Pamela P. Lombardo, D.D.S. Proposed Orthodontic Treatment
Pamela P. Lombardo, D.D.S. Proposed Orthodontic Treatment : Patient Name: Responsible Party: Length of Treatment months Treatment Plan Total $ Less Initial Payment $ Less Estimated Insurance $ Balance
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 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 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
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
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
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
Facebook. Jamboree Dentistry Website. Insurance. Mailer. Internet Search. Community Impact Newspaper Ad. Walk In. Online Appointment Request
On behalf of all our doctors and staff, we would like to personally welcome you to Jamboree Dentistry. The highest compliments we can receive are when our patients show a vested interest in establishing
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
New Patient Registration Form
New Patient Registration Form Welcome to ABC Dental Office! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
COSMETIC DENTISTRY CEREC IMPLANTS IV SEDATION
COSMETIC DENTISTRY CEREC IMPLANTS IV SEDATION WELCOME TO BELMAR PARK DENTAL CARE. WE SINCERELY APPRECIATE YOU CHOOSING OUR OFFICE FOR YOUR DENTAL AND ORAL HEALTH CARE NEEDS. PLEASE BE ASSURED THAT WE WILL
This type of treatment has been carried out over the last forty years - there is no incidence of tooth damage during that time.
Tooth Whitening What is tooth whitening? Tooth whitening is the procedure which lightens the colour of teeth. What causes tooth discoloration? Some of the most common causes include the consumption of
Course #:
Welcome to Lesson 7: Indicators of Problems of the Dental Health for Individuals with Disabilities webcast series. Please adjust your computer volume so that it is at a comfortable listening level for
Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
Jennifer Unger Waters, D.D.S., P.C. 1607 Washington Avenue Golden, CO 80401 (303)279-6621 WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely
PATIENT 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!