NEW Adult Patient Information

Similar documents
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:

WELCOME Patient Registration Date:

PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)

We Would Like to Get to Know You Better!

Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently

Julia A. Hallisy, D.D.S., Inc.

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

PATIENT MEDICAL HISTORY

GENERAL QUESTIONS CONTACT INFORMATION

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

Last: First: MI: Nickname:

Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip

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

Kingsland Family Dental Registration and Medical History

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

Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer

Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:

New Patient Paperwork

STEPHEN C. SNITZER, D.D.S.,

Patient Registration

Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4

MEDICAL HISTORY FULL NAME D.O.B. SEX

Welcome to Dr Jamie Italiane-DeCubellis s office

Medical and Dental Health History Form Getting to Know You As Our Patient

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 Registration

PATIENT INFORMATION DENTAL HEALTH HISTORY

Welcome to South 40 Dental! Tell Us About Yourself

PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:

KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N

(Please complete the enclosed forms prior to your visit and bring them in with you.)

Prosthodontics and Implant Surgery

Patient Information. Spouse or Responsible Party Information. Insurance Information

Highland Colony Dental- Donald K. Givan, DMD

Twohig Dentistry Dental and Oral Health Information

MEDICAL AND PERSONAL HISTORY

GIVE KIDS A SMILE. Sincerely,

MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose

PATIENT HEALTH HISTORY

Medical Health Information (continued):

Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:

Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:

Welcome to Dr. Halliday s Office

Fairfax Oral and Maxillofacial Surgery

Jason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology

PATIENT REGISTRATION

AJ Dental Group, PC Family, Cosmetic & Implant Dentistry

COLVIN AVENUE DENTAL. Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York WELCOME LETTER. Dear

PATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:

MEDICAL HISTORY. PATIENT NAME Birth Date

White House Dental 347 West Idaho Avenue Ontario, Oregon (541) whitehousedental.net

NEW PATIENT QUESTIONNAIRE

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

PATIENT REGISTRATION

PATIENT INFORMATION SCHOOL/LOCATION

Kids Dental Care Adult Patient Registration

New Patient Registration Form

Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:

Patient Name: D.O.B. Who may we thank for recommending us: Name of Dentist: Date of last visit:

Lake Forest Dental. Patient Information

Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:

Name: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:

TODAY S DATE FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? SOCIAL SECURITY #

Personal Information Protection Act Consent Form

Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.

Welcome to the office of

Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: Address: Birthdate: Age: Social Security Number:

Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)

HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.

Lake Forest Dental. Patient Information

Dental Patient Survey

Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,

PAUL T. OLENYN D.D.S.

Patient Medical and Dental History Personal Information. Name Date

Medical History Questionnaire

Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:

General Dentistry Cosmetic Dentistry Endodontics Oral Surgery Orthodontics Periodontics DENTAL HISTORY. How may we help you today?

Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-

History of Present Problem

ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!!

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Specialist in Orthodontics and Dentofacial Orthopedics

Medical History Questionnaire

PATIENT INFORMATION. Residence Address: (Street) (City) (State) (Zip)

NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY

Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.

Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION

Patient Health Questionnaire

PATIENT REGISTRATION FORM

Patient s Full Name Age Sex: (M) (F) Whom may we thank for referring you?

Chapel Hill Pediatric Dentistry

ADULT PATIENT REGISTRATION FORM Name Social Security # Gender Preference M F Transgender (M to F) Transgender (F to M)

ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY

General Dental Treatment Consent Form

Upperman Family Dental NEW PATIENT REGISTRATION

Dear Patient, Sincerely, Dr. Edward Adourian. carlsbaddentalassociates.com. Dental Associates & Orthodontics EXCELLENCE IN DENTISTRY

New Patient Information

If yes, please explain: Yes. If yes, please explain: Yes

How did you hear about our office?

Transcription:

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: single married separated divorced remarried widowed Patient s Dentist: Referred By: Physician: Names & Ages of Children: Work Phone: Employed By: Spouse s Name: Work Phone: Employed By: Responsible Party Information Person Responsible for Account last first middle Relationship to Patient: Birth date: Soc. Sec. #: Address (if different from patient) Phone: Person Responsible Employed by: Cell Phone/Alternate Phone: Business Address: Does the patient have dental Insurance coverage? Yes or No Business Phone: Dental Insurance Company: Address: Contact #: Subscriber Name: Subscriber Date of Birth: Subscriber #: Group #:

Medical History For the following questions mark yes, no, or don t know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation. Now or in the past, have you had: Birth defects or hereditary problems? Bone fractures, any major accidents? Rheumatoid or arthritic conditions? Endocrine or thyroid problems? Kidney problems? Diabetes? Cancer, tumor, radiation treatment or chemotherapy? Stomach ulcer or hyperacidity? Polio, mononucleosis, tuberculosis, pneumonia? Problems of the immune system? AIDS or HIV positive? Hepatitis, jaundice or liver problem? Fainting spells, seizures, epilepsy or neurological problem? Mental health disturbance or depression? Vision, hearing, tasting or speech difficulties? Loss of weight recently, poor appetite? History of eating disorder (anorexia, bulimia)? Excessive bleeding or bruising tendency, anemia or bleeding disorder? High or low blood pressure? Tired easily? Chest pain, shortness of breath or swelling ankles? Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)? Skin disorder? Do you have a well-balanced diet? Frequent headaches, colds or sore throats? Eye, ear, nose or throat condition? Hayfever, asthma, sinus trouble or hives? Tonsil or adenoid conditions? Osteoporosis? Allergies or reactions to any of the following: Local anesthetics (Novocaine or Lidocaine) Aspirin Ibuprofen (Motrin, Advil) Penicillin or other antibiotics Sulfa drugs Codeine or other narcotics Metals (jewelry, clothing snaps) Latex (gloves, balloons) Vinyl Acrylic Animals Foods (specify) Other substances (specify) Are you taking medication, nutrient supplements, herbal medications or non prescription medicine? Please name them. Do you currently have or ever had a substance abuse problem? Do you chew or smoke tobacco? Operations? Describe: Hospitalized? For: Other physical problems or symptoms? Describe: Being treated by another health care professional? For: Date of most recent physical exam? Do you have any other medical conditions that we should know about? Women Only: Are you pregnant? Are you anticipating becoming pregnant? Family Medical History: Do your parents or siblings have, or have ever had any of the following health problems? If so, please explain. Bleeding disorders Diabetes Arthritis Severe allergies Unusual dental problems Jaw size imbalance Any other family medical conditions that we should know about?

Dental History Now or in the past, has the patient had: Permanent or extra (supernumerary) teeth removed? Supernumerary (extra) or congenitally missing teeth? Chipped or otherwise injured primary (baby) or permanent teeth? Teeth sensitive to hot or cold; teeth throb or ache? Jaw fractures, cysts or mouth infections? Dead teeth or root canals treated? Bleeding gums, bad taste or mouth odor? Periodontal gum problems? Food impaction between teeth? Gum boils, frequent canker sores or cold sores? Thumb, finger, or sucking habit? Until what age? Abnormal swallowing habit (tongue thrusting)? History of speech problems? Mouth breathing habit, snoring or difficulty in breathing? Tooth grinding or jaw clenching? Any pain, clicking or locking in jaw or ringing in the ears? Any pain or soreness in the muscles of the face or around the ears? Difficulty in chewing or jaw opening? Have you ever been treated for TMD or TMJ problems? Aware of loose, broken or missing restorations (fillings)? Any teeth irritating cheek, lip, tongue or palate? Concerned about spaced, crooked or protruding teeth? Aware or concerned about under or over developed jaw? Any relative with similar tooth or jaw relationships? Any wisdom tooth problems? Had periodontal (gum) treatment? Had any serious trouble associated with any previous dental treatment? Been under another dentist s care? Specialist Other Ever had a prior orthodontic examination or treatment? Would you object to wearing orthodontic appliances (braces) should they be indicated? How often do you brush: floss: What is your primary concern? Why are you here? I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice. Signed: (Patient) Date Signed: Signed: (Dental staff member) Date Signed

Privacy Consent This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form. Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure). You have the right to review our office s privacy notice prior to signing this Consent, a copy of which was given to you with this Consent. You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request. We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice. You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent. Thank you for your cooperation. Please let us know if you have any questions. Patient s Signature Print Name Date If this consent is signed by a personal representative on behalf of the patient, please complete the following: Personal Representative s Name: Relationship to Patient

Acknowledgement of Receipt of Notice of Privacy Practices I,, have received a copy of this office s Notice of Privacy Practices. Print Name Signature Date We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify)

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback