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Medical Arts Press® Patient Registration and History Form
Item #:
901-39071
Model #:
39071
Brand:
Medical Arts Press
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250 EACH = 1 PACK
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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
Chart and Form Type
Standard Patient Registration Form
Color Family
Multicolor
Height in Inches
11"
Number of Pages
250
Series or Collection
General Health
Speciality Use
General Practice
True Color
Multicolor
Used For
Registration and History Form
Width in Inches
8.5"