Medical Arts Press® Patient Registration and History Form
$77.99
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Medical Arts Press® Patient Registration and History Form
Item #:
901-39071
Model #:
39071
Brand:
Medical Arts Press
(1 reviews)
Item #:
901-39071
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$151.97
$77.99
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$71.99
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Description
- Easy-to-complete form guides patient to insert complete Medical History
- Special sections alert Dentist to certain diagnoses and medication history requiring medical clearance
- Use with every patient on initial visit. Here are some of the form s features:
- General patient profile includes employer, person responsible for payment and referral information
- Patient verifies insurance coverage and responsibility for payment of the remaining balance
- Authorization for release of Protected Health Information and authorization for treatment
- Patient specifies any dental-related problems that may be a concern for a first visit
- Dedicated list of medical conditions requiring medical clearance
- Expanded list of allergies; Patient certifies accuracy of medical history
- Size: 8-1/2x11"
Specifications
Brand
Medical Arts Press
Form Size
8 1/2" x 11"
Length in Inches
11
True Color
White
Width in Inches
8.5