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Bayline/Intake/Jordan Hayes

Patient intake

Sample intake — Jordan Hayes · 10:00 AM cleaning + exam

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PT-1142 · Cleaning + exam (D1110) · 10:00 AM

Jordan Hayes

DOB 1988-02-19·Submitted Apr 30, 2026 at 8:01 AM·Intake complete

Contact details

Address147 Hawthorne Ln, Bayline, NY 11201
Phone+1 (917) 555-0220
Emailjordan.hayes@gmail.com
Emergency contactPat Hayes · sibling · +1 (917) 555-0231
Preferred pharmacyWalgreens · Court Street

Dental history

  • Last cleaning: Oct 14, 2025 (Bayline)
  • Last full-mouth radiographs: Apr 2024
  • Existing restorations: amalgam #19, composite #14
  • Wisdom teeth extracted 2008

Periodontal status

Last assessed Oct 2025 · Class I (gingivitis) · recall every 6 months

Medical notes & medications

  • No major medical conditions
  • Asthma (mild) · uses inhaler as needed
  • Pre-medication required: No
MedicationScheduleSince
Albuterol inhalerAs needed2009

Allergies

SubstanceSeverityReaction
Latexmoderaterash
Codeinemoderatenausea

Patient preferences

  • Prefers no nitrous oxide
  • Anxious during numbing — pre-warm anesthetic
  • Music preference: classical / podcast

Insurance

CarrierDelta Dental Premier
PlanDelta Dental PPO Plus Premier
Member IDD-77321-X
GroupGRP-08877
EligibilityVerified · plan year resets Jan 1, 2027
Benefits remaining$1,200 of $1,500 annual maximum

DELTA DENTAL · PPO

Premier

MEMBER

D-77321-X

JORDAN HAYESEFF 01/01/2026

Photo ID

DocumentDriver License (NY)
Number···-···-219
Expires11/2030
CapturedApr 30, 7:58 AM

Consents signed

  • Notice of Privacy Practices (HIPAA)

    Signed Apr 30, 7:59 AM

  • General consent to treat

    Signed Apr 30, 8:00 AM

  • Radiograph consent (bitewings)

    Signed Apr 30, 8:00 AM

  • Financial responsibility

    Signed Apr 30, 8:01 AM

← All demos