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Medical Arts Press® Patient Registration and History Form

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Item #: 901-39071
  Model #: 39071
Brand: Medical Arts Press
Medical Arts Press® Patient Registration and History Form
$71.99 Pack
When you buy 2+
250 EACH = 1 PACK
$77.99 Pack
When you buy 1
Buy more & save!
Qty 1 2+
Price $77.99 $71.99
Qty. Savings 7%
Price per each: $0.31 $0.29
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  • 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"
Brand : Medical Arts Press Chart and Form Type : Standard Patient Registration Form Color Family : Multicolor Customizable : No
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"
Weight : 2.92 lbs. per Pack