Читать книгу Managing Patients: The Patient Experience Guidelines for Pratctice Success - American Dental Association - Страница 12

FOR OFFICE USE ONLY:

Date:___________________________________________________________________________________

Patient name: ______________________________________________________________________________

Parent or legal guardian’s name: _______________________________________________________________

Address:__________________________________________________________________________________

Email: ____________________________________________________________________________________

Cell phone: ___________________ Home phone: _________________ Work phone: __________________

Contact Preference: Cell Text Home phone Work phone Email

How did you hear about our office?

Referral Website Signage Coupon Other: _________________________________

Referral Source: ____________________________________________________________________________

Are you experiencing any dental problems or have any dental concerns?

Pain? Where?_______________________ Constant? Occasional?

Swelling?Where?________________________

Are you under the care of a physician? Yes No

When was your last dental visit?_____________________ Are x-rays available? ______________________

Name of previous dentist: __________________________ Phone number: ___________________________

Address: __________________________________________________________________________________

Do you have a dental benefit plan? Yes No

If Yes:

Member ID number: _______________________________Group number: ___________________________

Name of policy holder: ______________________________________________________________________

Policy holder’s relationship to the patient: ______________________________________________________

Date of birth:______________________________________________________________________________

Policy holder’s employer: ____________________________________________________________________

Insurance company: _______________________________________________________________________

Address: __________________________________________________________________________________

Phone number and/or insurance company website: _____________________________________________

Scheduled appointment date: ________________________________________________________________

Verification of eligibility and benefits by: ______________________________________________________

Electronic Fax Verbal

Verification scanned, saved or written in record date: ___________________________________________

Maximum benefits/year: $______________

Deductible amount:$_______________

Has deductible been met? Yes No

Does deductible apply to preventive services? Yes No

Determine frequency of preventive services:

Twice per year

Once every six 6 months

Other: ______________________________

Date of last radiographs: ___________________________________________________________________

Prior tooth loss restrictions: _________________________________________________________________

Any other restrictions or limitations: __________________________________________________________

__________________________________________________________________________________________

Benefits remaining for benefit year: __________________________________________________________

Additional information:______________________________________________________________________

__________________________________________________________________________________________

© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice.