WELCOME TO OUR OFFICE Thank you for filling out this form accurately and completely. The information you provide will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask – we are always happy to help! PATIENT INFORMATION Name___________________________________________________________________Male____Female____ Minor______ Single______Married______ Divorced______ Separated______Widowed________ Mailing Address________________________________City,ST________________ Zip________ Birthdate_____________ E-Mail Address_____________________________________________ SS#_______________________Home Ph#__________________Cell#_____________________ Employer_________________________________________________Occupation_______________ Business Street Address__________________________City_________________ Zip_________ How Long at this job?_______________________ Wk Phone_____________________________ Children Only:School______________________________Grade_________________________ SPOUSE INFORMATION Name_______________________________________ Occupation________________________ Employer____________________________________Wk Phone__________________________ Business Street Address________________________ City________________Zip____________ RESPONSIBLE PARTY Person Responsible for Payment____________________________________________________ Relationship to Patient__________________________ ___Phone__________________________ Street Address________________________________City___________________Zip__________ Business Address _______________________________Wk Phone________________________
INSURANCE INFORMATION Name of Insured_________________________________________________________________ Relationship to Patient____________________Soc Sec # of Insured________________________ Birthdate of Insured_______________________Group# _________________________________ Insurance Co_______________________________Employer_____________________________ If more than one insurance company, please complete the following: Name of Insured_________________________________________________________________ Relationship to Patient____________________Soc Sec # of Insured________________________ Birthdate of Insured_______________________Group#__________________________________ Insurance Co___________________________Employer_________________________________ GETTING TO KNOW YOU Is another member of your family or relative a patient in our office? Name____________________________________Relationship____________________________ Referred to Us By________________________________________________________________ Person to Contact for Emergency_____________________________Phone#________________ Former Dentist__________________________________Last Appt_________________________ Medical Doctor__________________________________________________________________ Is there anything about the appearance of your teeth that you don’t like?(color,shape, size, spaces,cracks, chips, alignment, other________________________________________________
HEALTH HISTORY
PLEASE CIRCLE YES OR NO Yes No Are you currently taking ANY medications? If so, please list: _______________________________________________________________________ Yes No Are you allergic to penicillin, aspirin, or codeine? (Circle applicable ones) Yes No Are you allergic to any other drugs or medication? List___________________________ Yes No Have antiresorptive drugs (Fosamax,Boniva, Zometa, etc) been given in the past five years? Yes No Are you under treatment of a medical doctor? If so, state reason: _________________________________________________________________________ Yes No Do you smoke or chew tobacco? Yes No Have you ever had excess bleeding requiring treatment? Yes No Are you currently bleaching your teeth? WOMEN PLEASE CIRCLE YES OR NO Yes No Is there a possibility you may be pregnant? Yes No Are you nursing? Yes No Are you taking birth control pills? NOTE: Antibiotics (such as penicillin, erythromycin, etc.) and some medications may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control. HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CIRCLE YES OR NO Yes No Heart Disease or Attack Yes No Sexually Transmitted Disease Yes No Artificial Heart Valve Yes No Epilepsy or Convulsions Yes No Heart Pacemaker Yes No Fainting or Dizzy Spells Yes No Angina or Chest Pain Yes No High/Low Blood Pressure Yes No Asthma/Hayfever/Emphysema Yes No Hemophilia Yes No Sinus Trouble Yes No Kidney Trouble Yes No Diabetes (TYPE __________) Yes No Dialysis Yes No Artificial Joints Yes No Hepatitis (Type___________) Yes No Cancer Yes No Cortisone Medicine Yes No Chemotherapy/Radiation Yes No Pain in Jaw Joints FEES AND PAYMENTS We make every effort to keep down the cost of your dental care. You can help by paying upon completion of each visit (Cash, Check, Credit Card, or CareCredit-a special dental credit card.) An ESTIMATE of the charge for any procedure can be given to you. Please remember that insurance is filed as a courtesy to our patients. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. IT IS YOUR RESPONSIBILITY TO PAY ANY DEDUCTIBLE AMOUNT, CO-INSURANCE, OR ANY OTHER BALANCE NOT PAID FOR BY YOUR INSURANCE COMPANY. If the patient’s portion of the dental bill is not paid within 25 days of the monthly billing date, a late charge of 0.5% per month will be assessed. 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 to third party payers and/or other health practitioners. This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist named of the insurance benefits otherwise payable to me. Signature_________________________________________________Date____________
Problems associated with various ticks have been widely reported throughout much of the country including the areasurrounding Tomahawk Scout Reservation in Wisconsin. With proper planning and education, tick problems can beminimized. To assist troops with educating campers, the staff at Tomahawk has prepared the following plan:All campers should wear a good quality insect repellant when they are
CURRICULUM VITAE NORMALIZADO 1. ANTECEDENTES PERSONALES. Nombre completo: Pedro Luis Alfonso Hernández Navarro Fecha de ingreso a la Universidad de Concepción: diciembre 2006 Departamento de Suelos y Recursos Naturales 2. TITULOS, GRADOS Y PERFECCIONAMIENTO ACADEMICO Y PROFESIONAL. 2.1 Pontificia Universidad Católica de Valparaíso Perfeccionamiento académico y prof