Medical Arts Press® Patient Registration and History Form
Item #:
901-39071
Model #:
39071
Brand:
Medical Arts Press
(1 reviews)
Item #:
901-39071
Out of stock
$48.99
Per pack
250 EACH = 1 PACK
Item is out of stock in your zip code 60069. Please try another zip code or see Other alternate products similar to this item
Frequently bought together
+
Total
$78.78
Customers also viewed
ComplyRight™ Employee Records Folder, Letter Size, Pack of 25 (A5001)
Item #: 901-1949184
ComplyRight™ Personnel Pocket File Folder, Pack of 25 (A1202)
Item #: 901-1949182
Medical Arts Press® Progress Notes, No Imprint
Item #: 901-21757NP
Medical Arts Press® Progress Notes; Purple FormFamily™
Item #: 901-20643
ComplyRight™ Orthodontic Case Envelo-File®
Item #: 901-AR1048
ComplyRight™ Georgia Job Application, Pack of 50 (A2179GA)
Item #: 901-1182913EDI
Medical Arts Press® Progress Notes; Reinforced, Top Punched
Item #: 901-20555
Medical Arts Press Progress Notes; Standard 2-Hole Punch (20585RL)
Item #: 901-20585NP
ComplyRight™ Kansas Job Application, Pack of 50 (A2179KS)
Item #: 901-1182885EDI
ComplyRight™ Connecticut Job Application, Pack of 50 (A2179CT)
Item #: 901-1182917EDI
Medical Arts Press® Progress Notes Patient Care Form; Green FormFamily™
Item #: 901-20381
ComplyRight™ Texas Job Application, Pack of 50 (A2179TX)
Item #: 901-1182982EDI
ComplyRight™ Florida Job Application, Pack of 50 (A2179FL)
Item #: 901-1182914EDI
Medical Arts Press® Continuation Notes, Green
Item #: 901-20133NP
ComplyRight™ Illinois Job Application, Pack of 50 (A2179IL)
Item #: 901-1182911EDI
ComplyRight™ Ohio Job Application, Pack of 50 (A2179OH)
Item #: 901-1182986EDI
Medical Arts Press® Continuation Notes, Blue, No Punch
Item #: 901-20134NP
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
