You can find more Patient Information Forms below. Dental Emergency Information. 0000008800 00000 n Arthur Family Dental, LLC Patient Information Form Health History Form 2019.doc Staff Initials _____Date _____ Health Questions Any history of heart murmur/MVP or any other heart problems? Patient Relationship to Insured _____ To the best of my knowledge, the above information is correct. h�b```a``�c`e`jed@ A�P���� @���9KP gK�)9f%�T��2���s>1J:��zb�DEEGG�RR�2B�@�q �� You may also want to fill out a Medical Information Form for any medical emergency. Many practices have tried to streamline new patient dental form by putting intake PDF file forms on their website so their patients will be able to fill out the paperwork at home. 0000113273 00000 n We promise to do our best to provide you with the finest care available. %l��C�n��i.3�ౙ���3����|������V�ٷ)���M@�L�������քu���}1�3S9�ESGƶ�7ڢ��� �ƺ1%*�xI�G��C% An after hours fee may be charged. The main thing is that the patient understands any risks involved before they consent to treatment. h�bbd`b``�� �T6 endstream endobj 119 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog>> endobj 120 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 121 0 obj <> endobj 122 0 obj <> endobj 123 0 obj <> endobj 124 0 obj <> endobj 125 0 obj <> endobj 126 0 obj [/ICCBased 145 0 R] endobj 127 0 obj <> endobj 128 0 obj <> endobj 129 0 obj <> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj <>stream 0000003565 00000 n With this information, you will know what the trends are when it comes to which types of individuals usually get certain illnesses. We accommodate patients of record who experience dental emergencies after hours. 0000006883 00000 n � dK{��{m@�Jht�醡�Y�y9W���O���M��}`�VL� =� �)Szs��`��x�F:����/�<5g�rNA����\wm}��@� p��b� ���l{�[?��`�nm_�����K�b�ړs� �!K�7C���X��u���_RNj�_��QFm A#�{m�L�4���4�LXe�\Ϛ����j(&�����jtb��|c�5��lh��N4{�$��݀�N��. Patient Name:_____ _____ Date of birth:_____ Sex:____ Age:____ Home Address :_____ _____ City:_____ State:_____ Zip :_____ 0000004219 00000 n 0000001483 00000 n 0000011625 00000 n 0000003856 00000 n This is usually requested by the patient. In case of minor patients, it is required that one of the parents or legal guardian accompany the child and remain in the waiting room during all procedures. Patient Information Form Preferred Name: Zip Divorced City Cell # Single Spouse Group # Spouse Group # Married State Work # DOB Phone Circle one: Other Minor Person to contact in case of an emergency Whom may we thank for referring you Insurance Information Primary Policy Holder Name Relationship to policy holder Policy Holder DOB Insurance Compay For patients under the age of 18, a parent or guardian will need to sign the consent form. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that ... to telephone me at home or at my work to discuss matters related to this form. 0000061360 00000 n If you are a patient of record and have a dental emergency, you can call the of˜ice for information on how to contact us. Aspen Dental Appointment Guidelines. 0000003144 00000 n As hassle as filling out these patient forms could prove to be, once you understand the rationale behind them, you will begin to appreciate their importance. I will inform my dentist of any changes to my contact and/or trailer <<134CCBD2BB6E48419E4BADE4E49EE841>]/Prev 160699/XRefStm 1312>> startxref 0 %%EOF 153 0 obj <>stream Here’s what to expect with our Smile Wide, Smile Safe Promise. The consent forms and disclosure agreements are necessary so the hospital will not have any legal liability issues. As well, this information is not given away, sold, or used for anything other than Willamette Dental Group business. I accept the above conditions and hereby voluntarily give consent to Truman Medical Center Lakewood Dental Clinic and the dental staff to provide dental care encompassing routine diagnostic What are the types of Patient Information Forms? Update Patient Information Form: This is used if any information on a Patient Information Form should be updated. 0000004956 00000 n 0000064009 00000 n 0000004676 00000 n Patient Demographic Information Form: The purpose of this form is to categorize the patients based on their demographics for the purpose of statistical analysis. This is to certify that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of the local anaesthetic as indicated and I will assume responsibility for fees associated with those procedures. If you need your information to be disclosed to any other organization, you would need to sign Release of Information Forms for this purpose. Under medical history, there are a number of information bits that have to be included. 0000060918 00000 n %PDF-1.6 %���� That would be any allergies you might have if exposed to any food or medication, any current or past illnesses, family history of any illnesses, any surgeries whether major or minor, and current medications. The form should be sent to the patient’s insurer so that they may detail the type of medical work which will be covered by the patient’s plan (preventative, major, periodontal, etc.) For most thi s is a ro utine procedure, but for many patients it is perhaps the hig hlight of their visit and the only point at which they will have to interact directly with you. PATIENT INFORMATION Widowed Divorced Cell Phone # Thank you for trusting us with your dental care. 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