Kevin S. Brewer, D.M.D. 2505 Larkin Road, Suite 102 Lexington, KY 40503 (859) 277-7721 firstname.lastname@example.org We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we will be glad to help you. We look forward to working with you in maintaining your dental health. PATIENT INFORMATION Date________________________ HomePhone (___)___________________________ CellPhone (___)____________________________ Name_________________________________________________________________ Preferred Name____________________________ Last Name First Name Initial
Minor Sex M F
Partnered Soc. Sec. #_______________________________ Age_________ Birthdate________________ Address_________________________________________________ E-mail_________________________________________________ City____________________________________________________ State___________________________ Zip____________________ Patient Employer/School___________________________________ Employer/School Phone (___)______________________________ Employer Address_____________________City/ST/Zip__________________ Occupation________________________________ In case of emergency who should be notified? _________________________________Phone (___)______________________________ REFERRAL INFORMATION Whom may we thank for referring you to our practice? Name of person or office referring you to our practice: ________________________________________________________________ PRIMARY DENTAL INSURANCE Person Responsible for Account_____________________________________________________________________________________ Last Name First Name Initial Relation to Patient_________________________________________ Birthdate_______________ ID#/Soc. Sec. #___________________ Address (If different from patient’s)___________________________________________________ Phone (___)_________________________ City_____________________________________________________ State_______________________________ Zip________________ Person Responsible Employed By____________________________ Occupation_____________________________________________ Business Address__________________________________________ Business Phone (___)_____________________________________ Insurance Company_______________________________________________________________________________________________ Contract #_______________________________________________ Group #_____________________ Subscriber #________________ Name of other dependents covered under this plan______________________________________________________________________ ADDITIONAL INSURANCE Is patient covered by additional insurance? Yes No Subscriber Name________________________________________ Relationship to Patient_________ ______Birthdate____________ Address (If different from patient’s)__________________________________________________ Phone (___)__________________________ City_____________________________________________________ State______________________________ Zip_________________ Subscriber Employed by___________________________________ Business Phone (___)_____________________________________ Insurance Company_______________________________________ Soc. Sec. #______________________________________________ Contract #______________________________________________ Group # ____________________ Subscriber #________________ Names of other dependents covered under this plan_____________________________________________________________________ Kevin S. Brewer, D.M.D. 2505 Larkin Road, Suite 102 Lexington, KY 40503 (859) 277-7721 email@example.com DENTAL HISTORY Reason for Today’s Visit___________________________________________ Date of last dental care_____________________________ Former Dentist_________________________________________________ Date of last dental X-rays__________________________ Address__________________________________________________________________________________________________________ Check ( X ) if you have had problems with any of the following: How often do you floss?___________________________________ How often do you brush?_________________________________ MEDICAL HISTORY Physician’s Name_________________________________________ Date of Last Visit________________________________________ Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No Have you had any serious illnesses or operations? Yes No If yes, describe___________________________________________ Have you ever had a blood transfusion? Yes No If yes, give approximate dates______________________________ Have you ever been told you need to take an antibiotic prior to a dental or surgical procedure?
Yes No If yes, name of medication_________________________________ Are you pregnant?
Yes No Nursing? Yes No Taking birth control pills? Yes No Check ( X ) if you have had problems with any of the following: MEDICATIONS ALLERGIES List medications you are currently taking: _________________________________________________________ ________________________________________________
AUTHORIZATION I certify that I, and/or my dependent(s), have insurance coverage with _______________________________________ and assign directly to Dr. Kevin S. Brewer all insurance Name of Insurance Company(ies) benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. ___________________________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
Print name of Patient, Parent, Guardian or Personal Representative
PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED.
Many parents struggle with the decision of whether or not to send their possibly sick child to school. Juggling the demands of work and the demands of their students school work may make the decision even more difficult. It’s tempting to give a dose of Tylenol or Motrin and hope for the best. However, school age children are especially good at spreading germs and children cannot learn as effec
On the basis of the authorisation issued to it on 19 May 2005 by the General Meeting of the Slovene Association of Supervisory Board Members, the Administrative Board of the Slovene Association of Supervisory Board Members adopted on 23 June 2005 the fol owing RECOMMENDATIONS FOR THE APPOINTMENT, DISCHARGE AND MANAGEMENT OF REMUNERATIONS OF MANAGEMENT BOARD MEMBERS 1. PREAMBLE On t