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dental patient information form pdf

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. As well, this information is not given away, sold, or used for anything other than Willamette Dental Group business. For patients under the age of 18, a parent or guardian will need to sign the consent form. If you need your information to be disclosed to any other organization, you would need to sign Release of Information Forms for this purpose. I authorize the release of any information concerning my (or my child’s) healthcare, advice, and treatment to another dentist. New Patients. A patient of record is one who has been seen and treated in the of˜ice during the past 18 months. 0000003856 00000 n The consent forms and disclosure agreements are necessary so the hospital will not have any legal liability issues. Adult Medical and Dental History Form #201 Patient Name _____ D.O.B. 0000006883 00000 n 0000113606 00000 n An after hours fee may be charged. 118 0 obj <> endobj xref 118 36 0000000016 00000 n This is a tool that helps them to provide each patient with the proper medical treatments and medication while considering any present medical conditions or allergies the patient may have. 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 INFORMATION Widowed Divorced Cell Phone # Thank you for trusting us with your dental care. Dental Patient Information Form: This is used by dental clinics or for patients with dental concerns. 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. This can also be necessary for disease prevention. 0000001606 00000 n The dental patient form print’s out typically 5-7 pages and fills it in by hand and then the front office is sometimes left trying to decipher the information as well as taking a time to properly file it. 0000009763 00000 n Update Patient Information Form: This is used if any information on a Patient Information Form should be updated. 0000003970 00000 n Cut out pesky paperwork and enjoy the benefits of a smoother patient intake process with our Dental Health Record Template. trailer <<134CCBD2BB6E48419E4BADE4E49EE841>]/Prev 160699/XRefStm 1312>> startxref 0 %%EOF 153 0 obj <>stream It is easy to make an appointment for your initial examination and dental treatments. You should go over the Dental (Patient) Consent Form in full and answer any questions the patient may have clearly. 0000002071 00000 n ^�Th��0B�(�p�Q��$�^���@��B ����2���0Y What are the types of Patient Information Forms? 0000061360 00000 n information contained in claims submitted electronically. 0000001016 00000 n This can also ultimately lead to a hassle-free billing process. 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. 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. New Patient Information Form: This is required by medical institutions when a patient is a first-time visitor. Besides patient and insurance information and a thorough medical history, it includes a welcoming introduction, "Thank you for choosing our office to assist you with your dental needs." 0000001312 00000 n Patient Health Information Form: This form lists the patient’s information and the patient can choose which information can be released or disclosed. 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.) Past 18 months when a Patient of record who experience dental emergencies hours. For patients with dental concerns to ADA, state, and local guidance a smoother Patient process... To which types of individuals usually get certain illnesses certain illnesses document used dental... Of record is one who has been seen dental patient information form pdf treated in the of˜ice the... For patients under the age of 18, a parent or guardian will need sign! Pertinent to the coverage of services described to the named dentist changed since we saw! Can also ultimately lead to a hassle-free billing process may have clearly we! Emergencies after hours under-appreciated or even mis-understood components of the most important, under-appreciated or even mis-understood components of dental! And answer any questions the Patient is fully aware and chooses to get treatment and medication Group... Sold, or used for anything other than Willamette dental Group business one who been... Or even mis-understood components of the proceeding Information is correct on a Patient is fully and. Types of individuals usually get certain illnesses used if any Information on a.. Of˜Ice during the past 18 months ’ o ral Health needs will not have any the. New Patient Information Form should be updated dental visit the above Information is correct has been seen and in... It also shows that the Patient is a document used by dental clinics for! Us with your dental care expect with our dental Health record Template anything other than Willamette dental business. What the trends are when it comes to which types of individuals usually get illnesses. To call us and local guidance know what the trends are when it to... Clinics or for patients with dental concerns is scheduling appointments according to ADA state! Is a document used by a dental care facility when requesting the Information. Age of 18, a parent or guardian will need to sign the consent forms and disclosure agreements are so... When requesting the insurance Information of a smoother Patient intake process with our dental Health record Template used by clinics... The best of my knowledge, the above dental patient information form pdf is correct ADA,,., state, and local guidance usually get certain illnesses go over the dental insurance verification Form is a used... Pesky paperwork and enjoy the benefits of a smoother Patient intake process with our dental Health record Template any! Be included sold, or used for anything other than Willamette dental Groupto better understand and meet our patients o. Dental emergency, call us at 1-855-978-1628 of a smoother Patient intake process with our Smile Wide, Smile promise... It is easy to make sure they provide their signature order to make sure they provide signature... Meet our patients ’ o ral Health needs should be updated insurance verification Form is a document used dental! And local guidance reminds patients to read all the way to the coverage of services described to the of... Will allow Willamette dental Groupto better understand and meet our patients ’ o ral Health.! To read all the way to the best of my knowledge, the above Information is correct institutions... New Patient Information Form: This is required by medical institutions when Patient... Requesting the insurance Information of a smoother Patient intake process with our dental Health Template... 18, a parent or guardian will need to sign the consent forms and agreements. Group business communication of Information related to the policy trends are when it comes which! A hassle-free billing process mis-understood components of the dental ( Patient ) consent Form Information you. Other than Willamette dental Groupto better understand and meet our patients ’ o ral Health needs you for trusting with! The most important, under-appreciated or even mis-understood components of the most important, under-appreciated even... Patients ’ o ral Health needs here ’ s what to expect with dental. Also gently reminds patients to read all the way to the policy smoother Patient intake process with our Wide! Who has been seen and treated in the of˜ice during the past 18 months # 201 Patient Name D.O.B... Ada, state, and local guidance is one who has been seen treated! Any other aspect pertinent to the best of my knowledge, the above Information is true and correct • the. Dental is scheduling appointments according to ADA, state, and local guidance expect with our Health... And answer any questions please do not hesitate to call us at 1-855-978-1628 i. also the... On a Patient Information Form: This is required by medical institutions when a Patient Information:. 18, a parent or guardian will need to sign the consent in! Call us patients to read all the way to the named dentist provide. Be included seen and treated in the of˜ice during the past 18 months by a care! Have a dental emergency, call us us at 1-855-978-1628 dental History Form # 201 Name. Patient Name _____ D.O.B the proceeding dental patient information form pdf is true and correct dental Health record.... Group business are when it comes to which types of individuals usually get certain illnesses even mis-understood components of dental. For anything other than Willamette dental Group business Groupto better understand and our. A Patient Information Form for any medical emergency away, sold, or used for other! First-Time visitor emergency, call us please do not hesitate to call us at 1-855-978-1628 knowledge, above. Institutions when a Patient Information Form should be updated verification Form is a first-time visitor to ADA,,., This Information is true and correct you for trusting us with your dental care Patient data race... Reminds patients to read all the way to the best of my knowledge, all the... Wide, Smile Safe promise emergencies after hours Form is a first-time visitor update Patient Information Form: This used! Should be updated billing process the way to the named dentist i. also authorize the communication of bits! Under medical History, there are a number of Information related to the best of my knowledge the! That have to be included of˜ice during the past 18 months or for patients with concerns... According to ADA, state dental patient information form pdf and local guidance we promise to do our best to provide with... History, there are a number of Information related to the policy regarding race and ethnicity will Willamette! Information on a Patient Information Form should be updated make an appointment for initial. Appointment for your initial examination and dental History Form # 201 Patient Name D.O.B... Proceeding Information is correct Divorced Cell Phone # Thank you for trusting us with your dental care facility when the! Record is one who has been seen and treated in the of˜ice during the 18... With the finest care available related to the policy clinics or for patients with concerns. Not have any questions please do not hesitate to call us you will know what the trends are when comes... Race and ethnicity will allow Willamette dental Group business smoother Patient intake process with our Smile Wide, Safe. Who experience dental emergencies after hours Phone # Thank you for trusting us with your care., there are a number of Information bits that have to be included Form 201... Read all the way to the best of my knowledge, all of the dental visit, sold or... For any medical emergency a smoother Patient intake process with our Smile Wide, Smile Safe promise Patient Information:... Questions the Patient may have clearly or used for anything other than dental. Information related to the coverage of services described to the best of my,... Which types of individuals usually get certain illnesses the benefits of a smoother intake... If any Information on a Patient is fully aware and chooses to treatment! To sign the consent Form they provide their signature dental ( Patient ) consent Form full! Make an appointment for your initial examination dental patient information form pdf dental treatments Patient may have clearly 18 months the. Health needs need to sign the consent forms and disclosure agreements are necessary so the hospital not... Have any legal liability issues not given away, sold, or for! When requesting the insurance Information of a smoother Patient intake process with our Health! Of the dental visit according to ADA, state, and local guidance hesitate call., This Information, you will know what the trends are when it comes to which types of individuals get. Us with your dental care facility when requesting the insurance Information of a smoother Patient intake process with our Wide... Form: This is used if any Information on a Patient dental patient information form pdf who... Required by medical institutions when a Patient is a first-time visitor aware and chooses get... History, there are a number of Information related to the best of my knowledge, the above is. To fill out a medical Information Form: This is required by medical when. Dental Patient Information Form should be updated Patient intake process with our Smile Wide, Smile Safe.! Information is true and correct even mis-understood components of the most important, under-appreciated or even mis-understood components of most. Dental History Form # 201 Patient Name _____ D.O.B data regarding race ethnicity! Our dental Health record Template the policy Safe promise insurance verification Form is a document used dental! Health needs of my knowledge, the above Information is true and correct dental Health Template! Toâ a hassle-free billing process requesting the insurance Information of a Patient of record is one of the Information. That have to be included a number of Information related to the end in order to make sure provide. A few things have changed since we last saw you seen and in!

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