DENTAL REGISTRATION AND HISTORY PLEASE PRINT • ANSWER ALL QUESTIONSPATIENT INFORMATION DENTAL INFORMATION
Date _________________________________________________
_____________________________________________________
SS/HIC/Patient ID # _____________________________________
Relationship to Patient ___________________________________
Patient Name __________________________________________
Insurance Co.__________________________________________
_____________________________________________________
Group # ______________________________________________
Is patient covered by additional insurance?
Address ______________________________________________
Subscriber’s Name______________________________________
E-mail ________________________________________________
Birthdate _________________ SS#_________________________
City __________________________________________________
State _______________________Zip ______________________
Relationship to Patient ___________________________________
Insurance Co.__________________________________________
Birthdate __________________________________
Group # ______________________________________________
ASSIGNMENTAND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with
______________________________________ and assign directly to
Patient Employer/School _________________________________
Dr. ______________________________ all insurance benefits, if any,otherwise payable to me for services rendered. I understand that I am
Occupation ____________________________________________
financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Employer/School Address ________________________________
The above-named dentist may use my health care information and may
_____________________________________________________
disclose such information to the above-named Insurance Company(ies) andtheir agents for the purpose of obtaining payment for services anddetermining insurance benefits or the benefits payable for related services.
Employer/School Phone(______) __________________________
This consent will end when my current treatment plan is completed or oneyear from the date signed below.
Spouse’s Name ________________________________________
____________________________________________________________
Birthdate______________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
SS# _________________________________________________
____________________________________________________________Please print name of Patient, Parent, Guardian or Personal Representative
Spouse’s Employer _____________________________________
Whom may we thank for referring you? ______________________
PHONE NUMBERS
Phone (______)____________________ Work (______)____________________ Ext _____ Cell (______)____________________
Spouse’s Work (______) _________________________________
Best time and place to reach you______________________________
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name ________________________________________________
Relationship ______________________________________________
Home Phone (______)___________________________________
Work Phone (______) ______________________________________
ACKNOWLEDGEMENT AND AUTHORITY I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever drugs,medicine, performance of operations and conduct of laboratory, x-ray, or other studies that may be used by the attending doctor, or his nurse orqualified designate. The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing orprocessing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors oromissions that I may have made in the completion of this form. I also acknowledge full responsibility for the payment of such services and agree topay for them, in full, AT THE TIME OF SERVICE. In the event of default of payment your account will be turned over to a collection agency. I agree topay all reasonable court costs, attorney fees and collection fees up to 50% of the delinquent balance.
Date______________________Signature _______________________________________________________________
PATIENT, PARENT OR AGENT (MUST BE 18 YEARS OR OLDER)HEALTH HISTORY
Physician’s Name ________________________________________________
Date of last visit _________________________________
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelviz, Didronel, Boniva. q Yes q NoHave you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Lonimin, Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). q Yes q NoPlace a mark on “yes” or “no” to indicate if you have had any of the following:
Women: Are you pregnant?
q Yes q No Due date ___________________________
MEDICATIONS ALLERGIES
List any medications you are currently taking and the correlating
q Barbiturates (Sleeping Pills)q Penicillin
______________________________________________________
______________________________________________________
Pharmacy Name_________________________________________
Phone (______) _________________________________________
DENTAL HISTORY
Reason for today’s visit ___________________
Cigarette, pipe, or cigar smoking q Yes q No
Former Dentist __________________________
City/State ______________________________
Date of last dental visit____________________
Date of last dental X-rays__________________
Food collection between the teethq Yes q No
Place a mark on “yes” or “no” to indicate if you
q Yes q No Sores or growths in your mouth q Yes q No
q Yes q No How often do you floss?___________________
q Yes q No Loose teeth or broken fillings
q Yes q No How often do you brush?__________________
Patient’s Signature _______________________________________________________
Doctor’s Signature _______________________________________________________
International Journal of Drug Design and Discovery Volume 1 • Issue 2 • April– June 2010. 115-123 Synthesis and in vitro Biological Activity of Organic Charge-transfer Complexes of lansoprazole, fluconazole, gabapentin and gabalactum with Chloranilic and Picric Acids Lingappa Mallesha and Kikkeri N. Mohana* Department of Studies in Chemistry, University o
GELUSIL-S SCHEDULING STATUS: S0 PROPRIETARY NAME (AND DOSAGE FORM): Gelusil-S (tablet) COMPOSITION: Each tablet contains: Simethicone (activated methylpolysiloxane) PHARMACOLOGICAL CLASSIFICATION: A: 11.4.1 Antacids - Acid neutralisers. PHARMACOLOGICAL ACTION: Gelusil-S is a combination of two antacids, aluminium hydroxide and magnesium hydroxide plus a defo