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Medical Arts Press® Patient Registration and History Form

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Item # 901-39071
  Model # 39071
Medical Arts Press® Patient Registration and History Form
$63.99 Pack When you buy 8+

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250 EACH = 1 PACK
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Qty 1 2-3 4-7 8+
Price $79.99 $73.99 $66.99 $63.99
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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"
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