APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC
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1 APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC Patient Information (To be completed by the patient Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: Date: / / First Name: Middle Name: Home Address: City: State: Zip Code: Home Phone: ( ) Work Phone: ( ) Preferred Phone: ( ) address: Driver s License: California ID: [ ] Other Passport: Employer: Ethnicity: (please select) [ ] Asian [ ] Caucasian [ ] Hispanic [ ] Other [ ] African American [ ] American Indian/Alaskan native [ ] Pacific Islander [ ] Unknown Sex: [ ] Male [ ] Female [ ] Other Birth date: Primary Language(s) Spoken: Are you associated with U.S.C.? Yes / No (please circle) OFFICE USE ONLY HIPAA DMFS If so, how? Student Requested: Emergency Contact: Relationship: Emergency Contact Phone ( ) Major dental problem/reason for coming to USC School of Dentistry: Last Dentist: Phone: ( ) Address: City: State: Zip: Current Medical Doctor: Phone:( ) Address: City: State: Zip: Insurance/Financial Information (To be completed by the patient Please PRINT in ink) Previously a patient here? [ ] Yes [ ] No Year Insurance: [ ] Delta [ ] Delta/USC [ ] Denti-Cal [ ] Other Carrier Name: Subscriber: Subs. Subs. Birthdate: Relationship: Plan #: Group #: Person Responsible for Payment: Phone: Please be aware that your dental insurance may not pay for the total amount of your treatment and you may be responsible for any co-pays or amount that your insurance company does not cover. Revise 6/12, 6/13, 3/15 ER APP
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3 Medical History Questionnaire Herman Ostrow School of Dentistry of USC Patient Name: Date of Birth: Reason for visiting the School of Dentistry: Please answer all questions by checking a box under YES or NO. (Please do not draw a line.) Your responses will be held strictly confidential and will only be used to help assess your medical condition. If you have any hesitations, please express your concern to a member of our team. Do you have, or did you ever have, any of the following? Cardiovascular: High blood pressure Heart disease from childhood Heart murmur Rheumatic fever Use of Phen-Fen Pacemaker Vascular graft Heart valve replacement Heart attack Heart surgery Congestive heart failure Angina (chest pain) Irregular heart beat Stroke Increased cholesterol Endocrine/Hematologic/ Oncologic/Immune: Frequent hunger Frequent thirst Diabetes Thyroid disease Hemophilia Sickle cell disease Bleeding tendency Anemia Cancer Radiation therapy Chemotherapy HIV infection/aids Organ transplant Blood transfusion Do you have, or did you ever have, any of the following? Musculo-Skeletal/CNS/Developmental: Chronic jaw and facial pain Chronic headache pain Chronic neck pain Popping or clicking in your jaw Joint replacement Osteoarthritis Rheumatoid arthritis Spinal cord injury Seizures Dizziness Weakness Multiple Sclerosis Cerebral palsy Intellectual Disability Dementia / Alzheimer s Fainting spells Visual impairment Glaucoma Hearing impairment Gastro-Intestinal/Genito-Urinary: Hepatitis (A, B, C, or other?) Kidney dialysis Ulcers Sexually transmitted disease Denied permission to give blood Psychological: Anxiety / Nervousness Depression Mental health treatment Insomnia OVER PLEASE October 2012, rev 3/15
4 Respiratory: Asthma Chronic Sinus Problems Night sweats Emphysema Tuberculosis Other: Social: Do you use tobacco products? If so, how much? Do you drink alcohol? Every day? If so, how much? Do you use recreational drugs? Medication Allergy or Intolerance: Penicillin Dental anesthetic ( Novocain ) Aspirin Codeine Latex products Iodine Other: Do you have any medical conditions not already mentioned? History of Hospitalization/Surgical Procedures: Family: Did a parent, sibling or child of yours have any of the following? Diabetes High blood pressure Heart disease Bleeding tendency Cancer Medications: Are you taking any prescription medicines, any over-the-counter items, or any herbal medicines now? If so, please list them and the doses you use: Do you or have you used bisphosphonate medication (i.e. Fosamax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa and Bonefos ) to prevent or treat osteoporosis or as part of a cancer treatment? (If "yes", please ask your student for an informational page about bisphosphonate medications --- oral and/or intravenous) Other: Does the amount of saliva in your mouth seem to be too little? Does your mouth feel dry when eating a meal? FEMALES ONLY: Are you pregnant now? If so, # months Do you take birth control pills? Are you breast feeding now? To the best of my knowledge, all of the preceding answers are true. If I have any change in my health status, or any change in my medicines, I will inform my dental health care provider at my next appointment. Signature of patient (or Parent or Guardian if patient is under 18) Date Faculty: signature, number, and name PRINTED Student/ Resident : signature, number, and name PRINTED October 2012
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6 Emergency Patient Screening Form The Herman Ostrow School of Dentistry of USC Clinic Student # Chart Patient Information Last Name: Date: / / First Name: Nickname: Middle Name: Salutation: Mr. / Mrs. / Ms. / Dr. (Please circle) Referral Source [ ] Campus Ad [ ] Patient of the School [ ] USC Employees (non-dental) [ ] Dentistry Personnel [ ] Professional Referral [ ] Walk-ins [ ] Health Fairs [ ] School Outreach [ ] Yellow Pages [ ] Other Explanation of Emergency Dental Treatment and Fee The purpose of emergency dental treatment is to provide relief from pain, control of infection or bleeding or to restore function. In most cases, emergency treatment is temporary. Additional treatment, with additional cost is often needed to treat the problem, which created the emergency condition, or to save the tooth. Patients who receive emergency care at the USC Dental Clinic will be advised of what additional treatment, if any, is needed to avoid a recurrence of the emergency. Patients who wish to pursue additional treatment at the USC Dental Clinic should inquire about continuing as a regular/comprehensive patient of the Clinic. The fee for the emergency visit will be between $ This covers registration, examination, evaluation (including x-rays) and treatment of the emergency related to one tooth or area. The $ fee is non-refundable once the patient has been examined and his/her condition evaluated. If the patient chooses not to have the recommended treatment, copies of any x-rays that have been taken to evaluate the condition will be given to the patient, if requested. For security purposes, cameras are present throughout the school. The undersigned certifies that he/she has read and is willing to comply with the foregoing, and is the patient, the parent or guardian with authority to give consent, or is duly authorized by the patient as the patient s general agent to execute the above and accept its terms. Patient Signature Date Dental Student Signature Date Dental Badge # Faculty Signature Date Dental Badge # Clinic Assignment For Office Use Only Specialty Practice Assignment Care Level [ ] Ok to create chart Please Initial [ ] Advanced Specialty [ ] Emergency [ ] I-Consult [ ] III-Limited Treatment [ ] Faculty Practice [ ] Oral Surgery [ ] Special Patients [ ] II-Emergency [ ] IV-Comprehensive Care
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Last: First: MI: Nickname:
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Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
How did you hear about our office?
How did you hear about our office? Personal Information: Patient Name Social Security # Birthdate / / Address E mail Home Phone Mobile Work Employer Occupation Employer Address Spouse/Partner or Guardian
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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
Village Dental at Olde Raleigh Patient Registration
Village Dental at Olde Raleigh Patient Registration To our New Patients: We are thrilled you have chosen us to provide you with excellent dental care! We understand dentistry can sometimes be expensive,
Patient Intake Sheet
Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
Medical Questionnaire
Medical Questionnaire Date: Day Month Year Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in
Patient Enrollment Sheet
Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip