Welcome to Our Practice!
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- Letitia Dickerson
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1 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 friendly and extremely knowledgeable in caring for your dental concerns. Mission Statement: Our mission at All About Smiles Dentistry is to serve the community with superior dental care for the entire family. We strive to create a sense of calm, comfort, and kindness for our patients. We value honesty and only recommend treatment for our patients that we would have for ourselves. Patients will be at ease knowing that our entire staff attends continuing education courses regularly to stay current with the latest advances in dentistry. At All About Smiles we aim to keep our appointment times because we value your time as we expect you to respect ours. Enclosed please find a patient health history, our appointment policy, and a copy of our financial options. Will you please take a moment to fill out the enclosed paper work, sign where appropriate and bring with you the day of your appointment? We look forward to meeting you soon! Please call if you have any questions. Dr. Jason, Dr. Chasity, and Staff 724 N. Washington Ave P.O. Box 1637 Durant, Oklahoma Fax
2 Dr. Jason Carper, D.D.S. ~ Dr. Chasity Carper, D.D.S. All About Smiles Appointment Policy We are pleased you have chosen to become patients at our office. We take pride in our office and our practice, and will strive to make dental visits a pleasant, even enjoyable, experience for you and your family. Because we know your time is valuable, as is our time, it is necessary for you to arrive at your appointment on time. We do not put more than one patient in each appointment block. Your time schedule is reserved especially for you. Therefore, it is of utmost importance that you are on time. If you are more than ten minutes late for your scheduled appointment, we reserve the right to reschedule you to another day and/or time. Rushing through dental treatment because of patient tardiness can compromise the results of that treatment, and is unacceptable to our dental team, and most importantly, to you! In addition, our office must be notified if you will be unable to keep a scheduled appointment. For your convenience, you may call the office 24 hours a day, seven days a week to leave a message. Cancellations must be made at least 48 hours before your appointment. This gives us adequate time to call and appoint other patients needing treatment. If you cancel your appointment without giving at least 24 hours notice, or if you fail to keep an appointment without giving our office any notification two times within the course of one year, it will be necessary for you to seek dental treatment at another dental office of your choosing. Again, we would like to thank you for allowing us to serve your dental needs. We value and appreciate you as a patient and as an individual. If we can do anything to make your experience here more enjoyable and relaxing, please do not hesitate in informing us. Thank you for your cooperation. 724 N. Washington Ave P.O. Box 1637 Durant, Oklahoma Fax
3 PATIENT MEDICAL HISTORY Name: Date of birth: 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 an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician s care now? If yes, Specify: Have you ever been hospitalized or had a major operation? If yes, Specify: Have you ever had a serious head or neck injury? If yes, Specify: Are you taking any medications, pills, or drugs? If yes, Specify: Do you take, or have you taken, Phen-Fen or Redux? If yes, Specify: Do you use tobacco? If yes, Specify: Do you use controlled substances? If yes, Specify: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Do You Snore? / Trouble Sleeping? / Tired During the Day? / Restless Leg Syndrome/ Use CPAP? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? *Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Other If yes, explain: *Are you required to pre-medicate with antibiotics before dental treatment? If answer was yes for premed, please list reason why: PREFERRED PHARMACY: 1
4 Do you have, or have you had, any of the following: PATIENT MEDICAL HISTORY Aids/HIV Positive Alzheimer s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cortisone Medicine Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Diabetes Drug Addiction Easily Winded Emphysema Epilepsy Excessive Bleeding Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Joint replacement or implant Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatment Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Seizures Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Have you ever had any serious illness not listed above? If yes, please explain: I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I understand the above information, and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. Print Name Signature Date Adult Patient Parent or Guardian Spouse Doctor Signature Date 2
5 PATIENT DENTAL HISTORY Name: Date: Date of birth: Date of last dental exam: Reason for this visit? Previous dentist? How often do you brush your teeth? Floss your teeth? Do your gums bleed while brushing or flossing? Are your teeth sensitive to hot or cold liquids/foods? Are your teeth sensitive to sweet or sour liquids/foods? Do you feel pain to any of your teeth? Do you have any sores or lumps in or near your mouth? Have you had any head, neck or jaw injuries? Have you ever experienced any of the following problems in your jaw? Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing Do you have frequent headaches? Do you clench or grind your teeth? Do you bite your lips or cheeks frequently? Have you noticed any loosening of your teeth? Does food tend to become caught between your teeth? Have you ever had periodontal treatment (gums)? Ever worn a bite plate or other appliance? Have you ever had any difficult extractions in the past? Have you ever had any prolonged bleeding following extractions? Do you wear dentures or partials? If yes, date of placement Have you ever received oral hygiene instructions regarding the care of your teeth and gums? IF YOU COULD CHANGE ANYTHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE? AUTHORIZATION AND RELEASE I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care o third party payros and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all service rendered on my behalf of my dependents. Signature of Patient or Parent/Guardian if Minor Date 3
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7 Office Financial Options It is our goal to make financing of dentistry comfortable for all of our patients families. We realize that dentistry may be costly. We feel the following options will meet the needs of most of our patients. 1. Payment by appointment. (This options lets you spread out your payments according to your treatment plan.) 2. MasterCard, Visa, American Express or Discover 3. 3 to 18 month interest free or extended financing through Care Credit. (Please see our business team for further information.) 4. A 10% reduction in your fees if there is no insurance to file. If payment goes past due we reserve the right to add reasonable & customary fees for collection or attorney fees. With Regards to Insurance Benefits Insurance benefits are designed to cover some, but not all, of your dental services. We will be happy to submit your services to your insurance company as long as you have provided us the appropriate information prior to services being rendered. Insurance is not meant to be a pay all. Please know that most always there will be a co-payment due at the time of each service. Most insurance companies let you choose your own dentist. All insurance companies have their own fee schedules. These fees are not always the same as the fee your dentist charges for the same services. Example if your dental insurance company states they allow two FREE cleanings a year; what they mean is they will pay up to 100% of THEIR fee for a cleaning, exam and x-rays. Meaning, if your dentist charges $70.00 for a cleaning and your dental insurance fee schedule states that they pay 100% BUT their fee is $60.00; the patient ends up owing their dentist an additional $10.00 because of the difference in the fee schedule of the dental insurance vs. the dental office. You are responsible for all differences in the fees between the insurance company and the dental office, unless your dentist has a contract with your specific dental insurance company to accept the fees that the insurance dictates. Our doctors HAVE CONTRACTS with the following insurance companies: 1. Delta Dental of Oklahoma Premiere provider only 2. Blue Cross Blue Shield of Oklahoma 3. Cigna Radius Network only 4. Health Choice aka STATE Insurance 5. Oklahoma Health Care Authority Sooner Care Children only 6. Metlife dental We will bill ALL insurance companies for payment. If, however, your insurance is not one of the companies listed above, there MIGHT be a difference in fees, in addition to your copay, that you would be responsible for. We strive to give our patients our best GUESS and will always submit for a written authorization from your insurance company for any treatment recommendations above $500 so you, as the patient, will have minimal surprises as to what your out of pocket cost is after your insurance company pays. I have read and understood the above statements. Signature Date 724 N. Washington Ave P.O. Box 1637 Durant, Oklahoma Fax
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,
If yes, please explain: Yes. If yes, please explain: Yes
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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
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
Welcome to Dr. Halliday s Office
Dentist Medical Dr. Welcome to Dr. Halliday s Office Patient information: Today s Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Home Tel.( ) Cell.( ) Have you
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
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 #: (
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
We are delighted and honored that you have chosen us to provide your child with the best dental care possible. We to treat children in our practice!
Welcome To We are delighted and honored that you have chosen us to provide your child with the best dental care possible. We love to treat children in our practice! The first visit to the dentist may be
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 #:
MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline
ORAL CONSCIOUS SEDATION DOCUMENTATION FORM
ORAL CONSCIOUS SEDATION DOCUMENTATION FORM PRIOR TO THE SEDATION APPOINTMENT Patient Name of Sedation Appointment of Birth Medical Status: ASA Class Weight Baseline Blood Pressure Baseline Pulse Baseline
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
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
Fairfax Oral and Maxillofacial Surgery
Fairfax Oral and Maxillofacial Surgery Patient information: Today s Date Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Sex: Male Female Birth Date Age Soc. Sec. # E-mail Street Apt. City State Zip
NEW Adult Patient Information
NEW Adult Patient Information Patient Information Patient s Name: last first middle likes to be called Date of Birth: Age: Sex: E-Mail: Phone: Cell Phone/Alternate Phone: Home Address: Marital Status:
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
Patient Registration Last Name First Name Middle Initial Street Address Apt/Unit City, State Zip Home Phone Cell Phone (Text ok? ) Email Address Primary Number to call first: Birth Date / / Age Sex Marital
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
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
Dental Patient Survey
Dental Patient Survey Please assist us in making your in-office experience a memorable one Please indicate your language of preference: English Spanish Chinese Other 1. Where did you find us: Our website
Welcome To Our Office
Welcome To Our Office Our practice is dedicated to providing technically excellent comprehensive dental care in a relaxed and caring environment. Our goal is to work with you in keeping your smile for
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:_
Island Point Dentistry LLC, P.A.
Island Point Dentistry LLC, P.A. PATIENT REGISTRATION First Name: Last Name: Middle Initial: Preferred Name: Address: Street/PO Box: City, State, Zip : Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Ext: