STEPHEN C. SNITZER, D.D.S.,
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- Randolf Shields
- 6 years ago
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1 STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI (314) NAME How would you prefer to be addressed? DATE OF BIRTH SEX WEIGHT HEIGHT SOC. SEC. # ADDRESS: HOME: Street PHONE: City State Zip CELL: BUSINESS: Company Name PHONE: Street OCCUPATION: City State Zip SPOUSE'S NAME (PARENTS - IF CHilD) SPOUSE'S OCCUPATION SPOUSE'S SOC. SEC. # SPOUSE'S DATE OF BIRTH SPOUSE'S EMPLOYER PHONE: Company Name Is this person an emergency contact? If not: Street City State Zip REFERRED BY: Name Phone PRIMARY DENTIST: DO YOU HAVE DENTAL INSURANCE?: PRIMARY DENTAL INSURANCE COMPANY: ** Relationship to insured: Insurance Company Name Street Address of Insurance Company Phone # Self Spouse Other City State Zip SECONDARY DENTAL INSURANCE COMPANY: Policy ID # Insurance Company Name Group # Phone # ** Relationship to insured: Street Address of Insurance Company Self Spouse Other City State Zip Policy ID # Group #
2 NAME: DATE: Please complete the following questionnaire. This information is necessary for proper evaluation of your periodontal problem. Answers to the following questions are for our records and will be considered confidential. 1. Are you in good health?. 2. Are you now under the care of a physician?. 3. The name, address and phone number of my physician is 4. My last physical exam was on 5. Have you ever been hospitalized or had a serious illness or operation? EXPLAIN Do you have or have you ever had any of the following diseases? a. Rheumatic fever or rheumatic heart disease. b. Congenital heart disease. c. Cardiovascular disease (heart trouble. heart attack, mitral valve prolapse, other valvular disease, stroke, heart murmur). d. Artificial hip, knee or other joint replacement. e. High blood pressure,. f. Allergies. g. Hay fever,. h. Asthma. i. Fainting spells or seizures. j. Diabetes. k. Hepatitis, jaundice or liver disease. I. Arthritis or inflammatory rheumatism (painful swollen joints). m. Stomach or intestinal ulcers n. Kidney or bladder trouble o. Tuberculosis p. Epilepsy q. Bleeding or clotting problems. r. Low blood pressure s. Emotional problems..., t. Anemia or other blood disorders u. Glaucoma v. Acquired immune deficiency syndrome (AIDS) or HIV positive w. Alcohol or drug abuse......,. 7. Do you have chest pain upon exertion? Do you smoke? If yes, how much?. This form continues on the reverse side of this page
3 9. Are you ever short of breath after mild exercise?. 10. Do you have to urinate more than six times a day?. 11. Are you thirsty most of the time?. 12. Have you had abnormal bleeding associated with previous surgery, extractions or accidents?. 13. Do you bruise easily?. 14. Have you ever required a blood transfusion?. 15. Have you ever had surgery or x-ray treatment for a tumor, growth or other condition? (Include cosmetic surgery) 16. Are you taking any of the following? Please list the name of any medication you are taking, the dosage and how often you take the medication. a. Antibiotics or sulfa drugs. b. Anticoagulants (blood thinners). c. Medicine for high blood pressure. d. Cortisone or steroids. e. Tranquilizers. f. Aspirin. g. Dilantin. h. Insulin or other drug for diabetes. i. Digitalis or drugs for heart trouble. j. Nitroglycerin. k. Birth control "pill". I. Vitamins and herbal supplements. m. Other Are you allergic to or have you ever reacted adversely to any of the following? a. Latex. b. Local anesthetics (Novocaine, etc.). c. Penicillin or other antibiotics (please list). d. Sulfa drugs. e. Barbiturates, sedatives or sleeping pills. f. Aspirin. g. Codeine or other pain medication (please list). h. Other 18. Have you had any of these drugs intravenously or orally for cancer or osteoporosis: Zometa, Aredia, Fosamax, Actonel or Boniva?. 19. Are you employed in any situation which exposes you to x-rays or other ionizing radiation?. 20. Do you have any other disease or condition that you think I should know about that was not listed? Explain Women 21. Are you pregnant? If so, due date 22. Are you nursing?. 23. Have you reached menopause? ~.
4 Dental Questionnaire Please answer the following questions about your dental health: 1. My mouth is: A. very comfortable. B. moderately comfortable. C. uncomfortable. 2. I: A. think the appearance of my mouth is excellent. B. am satisfied with the appearance of my mouth. C. am dissatisfied with the appearance of my mouth. 3. I: A. will do anything to keep my natural teeth. B. want to keep my teeth, but have a certain budget of time and money that I am willing to spend on them. C. don't care whether I keep my teeth or not. 4. I: 5. I: 6. I: A. have set goals for my oral health with my referring dentist. B. want to set goals concerning my dental health. C. never set goals concerning my dental health. A. have always done the best that was recommended for me. B. have not done what dentists have recommended for me. C. rarely go, and do not care much about having dental work completed. A. put dentistry for myself and family high on the priority list. B. put dentistry for myself and family low on the priority list. C. do not consider dentistry a priority. 7. I think my present state of dental health is: A. excellent. B. good. C. fair. D. poor. 8. I aspire to a mouth that is: A. in excellent health. B. in good health. C. pain free. 10. Have you had any serious trouble associated with previous dental treatment? 11. Is there anything you would change about your mouth or the appearance of your teeth? 12. These are the things that are important to me about my dental health: 13. What are some questions about dentistry and oral health that you have never had adequately answered? This form continues on the reverse side of this page
5 14. What is your number one concern about your mouth or jaws? 15. Do you have an immediate problem that you would like cared for today? If so, please explain 16. How long have you been with your present dentist? 17. How frequently have you had your teeth cleaned by a dentist or dental hygienist? 18. Has your present dentist done most of your dental treatment? 19. Has your dentist discussed your periodontal problem with you? 20. Have you noticed any of the following conditions occurring in your mouth? Bleeding gums Do Have you you grind have hadfrequent or periodontal clenchheadaches? your treatment teeth? previously? If yes, to hot, cold or biting? Floss your teeth? If yes, do you wear a bite guard? 25. Does food wedge between your teeth? 26. Haveyouhadorthodontic~e~me~? 27. How do you feel about the possibility of wearing dentures? The above information is accurate to the best of my knowledge. I authorize the release of information from my dentist or physician to Dr. Stephen C. Snitzer. I authorize Dr. Stephen C. Snitzer to release information to my dentist or physician. Signature of Patient or Responsible Party Date
6 TO OUR PATIENTS WITH DENTAL INSURANCE Patient Signature Date Our office is happy to assist you with your insurance claims to help you achieve the maximum benefits under your plan. We will file for predetermination of benefits, if required, and file claims as your treatment progresses. To do so, we will require forms from your insurance company completely filled out and signed. We will accept payment directly from the insurance company if we receive your forms properly filled out in a timely manner. We will try to explain your coverage to you to the best of our ability. However, due to the variations among policies, your questions are best answered by your agent or employee benefits office where you work. No insurance plans cover 100% of treatment costs. Most plans have deductibles or co-payments that are the patient's responsibility. You will be expected to pay the estimated non-covered portion of treatment fees as your treatment progresses. If claims have not been paid within two (2) months from the time they were submitted, we will request that you contact your insurance company regarding the claim. All charges that have not been paid within three (3) months of the time that the claim was submitted are payable by the patient. The patient is ultimately responsible for all charges regardless of insurance coverage. I HAVE READ AND UNDERSTAND THE ABOVE. I AUTHORIZE THE RELEASE OF ANY INFORMATION REGARDING MY TREATMENT TO MY INSURANCE COMPANY OR THEIR REPRESENT ATIVES. I ALSO AUTHORIZE PAYMENT OF INSURANCE BENEFITS OTHERWISE PAYABLE TO ME TO BE PAID TO THE DENTIST. A PHOTOCOPY OF THIS SIGNATURE SHALL BE AS VALID AS THE ORIGINAL.
PATIENT INFORMATION DENTAL HEALTH HISTORY
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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
Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA 93442 (805) 772-8585 Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone
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 ( )
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
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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 #:
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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
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
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 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:
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 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 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
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
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
Patient Registration
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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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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 #:
Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
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Patient Registration Form
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Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
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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, 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
PATIENT INFORMATION. Whom may we thank for referring you to our office?
PATIENT INFORMATION Patient s Name Male Female Last First Middle I prefer to be addressed as E-Mail address Address Street Apt # City State Zip Birthdate / / Social Sec# Driver Lic# Marital Status Home
PATIENT INFORMATION DATE PATIENT INFORMATION INSURANCE INFORMATION PERSON TO CONTACT IN CASE OF EMERGENCY. r: No METHOD OF PAYMENT AUTHORIZATION
PATIENT INFORMATION DATE NAME MARRIED SINGLE MINOR MALE FEMALE LAST FIRST M SOCIAL SECURITY # ADDRESS BIRTHDATE STREET APT. # CITY STATE ZIP TELEPHONE MONTH DAY YEAR HOME WORK CELL E-MAIL NAME OF EMPLOYER
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
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
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
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
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please circle): Male Female Age: Date
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
PATIENT INFORMATION. Patient name: Date of birth: Sex: Age: Home address: City: State: Zip: Billing address (if different): City: State: Zip:
PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. Yvette E. Thompson, D.D.S. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please
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
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
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
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
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
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: