Patient Information Patient Name: «LName», «FName» «MI»



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Patient Information

Patient Name: «LName», «FName» «MI» «PrefName» Date: 12/06/2016

Last, First MI (Preferred Name)
Social Security #: «SS» Birth Date: «BirthDate» Phone (Home): «HPhone» Gender: F
Address: «Street» «Street2» «City» «State» «Zip»

Street Apartment # City State Zip Code



Referral Information

Whom may we thank for referring you to our practice? Another patient Advertisement _________________________


Dental Office Yellow Pages Insurance Company School Name of person/office: «RefBy_Name»

«RefBy_Title»Sydney«RefBy_MI»

Mother (or Guardian) Information

Guarantors Name: ____________________________ Male Female Married Single Other _________


Social Security #: ________________________________ Birth Date:_________/________/__________

Phone (Home): _«HPhone»__ (Work): _______________Ext: ______ (Cell): _______________

If address is the same as child please check here

Address: ____________________________________________________________________________________________________

Street Apartment # City State Zip Code

Employer: _____________________________________________ Email: ____________________________________________


Father (or Guardian) Information

Guarantors Name: _____________________________ Male Female Married Single Other __________


Social Security #: ________________________________ Birth Date:________/________/___________
Phone (Home): _«HPhone»__ (Work): _______________Ext: ______ (Cell): _______________

If address is the same as child please check here

Address: : ____________________________________________________________________________________________________

Street Apartment # City State Zip Code

Employer: _____________________________________________ Email: ____________________________________________


Name of Insurance Company: ________________________Policy Number:_________________________________________

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

TO THE PATIENT/ PERSONAL REPRESENTATIVE- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my child’s protected health information to carry out treatment, payment activities and healthcare operations.

FINANCIAL POLICY

Pediatric Dentistry at Vinings is committed to providing your child with the best possible dental care. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to treatment. Payment for all services provided by the practice is due in full at the time the services are rendered. If you have private insurance, we will file your visit. Your full co-payment is expected per visit. You will be billed in full for any services that your insurance plan deems to be a non-covered service or any balances due after we have received payment from your insurance carrier. All patient balances are payable upon receipt of the statement. We accept Cash, debit & credit cards (Visa, MasterCard, AMEX, and Discover Card) as payment for services rendered. Personal checks are not accepted. Refunds will be handled as a credit to the patient’s account or issued a check. Pediatric Dentistry at Vinings reserves the right to turn any patient over to collections if it is deemed that the account has been in default of the payment obligations or compliance of this policy. You will be responsible for all collections related fees which may represent 1/3 of the balance due.



APPOINTMENT POLICY

All our patients are seen on a reserved appointment basis. In most cases, the procedure you are scheduled for requires that a definite amount of time be set aside with the dentist or hygienist. This assures the best possible care for your child. Every effort in scheduling is made to minimize waiting. All appointments must be verbally confirmed with the office within the week of your appointment. The office will make every attempt to confirm your appointment. If you must reschedule your appointment, please contact our office as soon as possible. Giving us this courtesy allows us to schedule another patient who wishes to be seen. Appointments that are not cancelled at least 24 hours in advance will be considered a broken appointment and will be charged a $25.00 fee. A good dentist/patient relationship is based upon understanding and good communications. If you have any questions about financial arrangements, please feel free to speak with our Business Manager. We will make every effort available to you to clarify any misunderstanding you may have concerning your account. We are here to help you.

I have read, understand and agree to the terms of the above Financial and Appointment Policy of Pediatric Dentistry at Vinings.
Signed: _____________________________________________________ Date: _______/_______/_________

Child’s Name «LName», «FName» «MI» «PrefName»_____ HEALTH HISTORY



GENERAL HEALTH REVIEW Please review your child’s past and present health history. Mark the box ONLY if your child has the condition now or has been treated in the past.

THE EYES, EARS, NOSE AND THROAT THE LUNGS





  • Allergies

  • Chronic Earaches

  • Deafness/Hearing Loss

  • Speech Problems

  • Chronic Sore Throat/Tonsillitis

  • Tonsils/Adenoids Removed

  • Blindness/Low Vision

  • Other

  • Asthma Date of last attack_________________

  • Uses inhaler as needed

  • Uses daily oral medicines or inhaler

  • Uses steroids or has used steroids

  • Bronchitis

  • Pneumonia

  • Tuberculosis

  • Other ___________________________________



THE CIRCULATORY SYSTEM THE NERVOUS SYSTEM, MUSCLES AND BONES




  • Heart Murmur

  • Antibiotics for previous dental work

  • Circulation Problems

  • Epilepsy or Seizure

  • Fainting

  • Cerebral Palsy




  • Congenital Heart Problems

  • Heart Surgery

  • Artificial Heart Valve

  • Nervous Problems

  • Mental retardation

  • Down Syndrome




  • Rheumatic or Scarlet Fever

  • Excessive Bleeding/Hemophilia

  • Hepatitis

  • Autism

  • Attention Deficient Disorder

  • Head Trauma/Brain Injury




  • Sickle Cell Anemia

  • HIV/AIDS

  • Leukemia

  • Spina Bifida

  • Muscular Dystrophy

  • Orthopedic Problems




  • History of Blood Transfusion Date___________

  • Other

  • Artificial Joints

  • Other





THE STOMACH, LIVER, KIDNEYS, BLADDER ALLERGIES



  • Stomach Problems

  • Diabetes

  • Allergy to food, food additives

  • Allergy to household items, dust, pets




  • Kidney Problems

  • Hepatitis

  • Allergy to plants, pollen, grass

  • Allergy to latex rubber




  • Bladder Problems

  • Other

  • Allergy to Drugs. Specify

  • Other





INFECTIONS AND SERIOUS ILLNESSES GROWTH AND DEVELOPMENT



  • Immunizations are up-to-date

  • Chicken Pox

  • Prematurely or complicated pregnancy

  • Birth defects




  • Chemotherapy Date(s)

  • Hospitalization. Date(s)

  • Concerns with growth

  • Learning, behavioral, or communication problems



  • Cancer or other malignancies

Type

  • Psychological problems, testing or counseling

  • Alcohol, tobacco, or drug use



LIST ANY MEDICATIONS YOUR CHILD IS PRESENTLY TAKING: __________________________________________________________________________________




IS THERE ANYTHING ELSE WE NEED TO KNOW ABOUT YOUR CHILD’S HEALTH HISTORY? ________________________________________


Pediatrician Phone # ( ) ____ _- ______



DENTAL HEALTH AND HABITS

Please mark only the boxes that apply to your child.

  • MY CHILD HAS HAD REGULAR DENTAL EXAMS AND CLEANINGS. DATE OF LAST DENTAL APPOINTMENT: _______/________/__________

  • MY CHILD PRESENTLY TAKES A FLUORIDE SUPPLEMENT

  • DENTAL X-RAYS WERE TAKEN AT EARLIER VISITS WITH DR.

  • MY CHILD WAS BREAST OR BOTTLE FED FOR MORE THAN 1 YEAR

  • MY CHILD SLEPT WITH A BABY BOTTLE. (What was in the bottle? ___________ )

  • MY CHILD SUCKS A THUMB OR FINGERS.OR A PACIFIER (Please circle)

  • MY CHILD IS A MOUTH BREATHER

  • MY CHILD GRINDS or CLINCHES TEETH.

  • INJURY TO MOUTH AND/OR TEETH.

  • BLEEDING GUMS

  • ARE THERE ANY OTHER DENTAL CONCERNS TO YOU AS A PARENT? ___________________________________________________________________________



FIRST VISIT INFORMATION (only new patients and their parents need to complete this section)

  • THIS IS MY CHILD’S FIRST DENTAL VISIT.

  • MY CHILD IS WORRIED ABOUT TODAY’S VISIT

  • MY CHILD’S PREVIOUS VISITS WERE UNSATISFACTORY.

  • MY CHILD HAD AN ACCIDENT, HURTING THE HEAD, MOUTH, OR TEETH

  • MY CHILD HAS HAD A TOOTHACHE RECENTLY? (Please circle) When eating only or Keeps him/her up at night

WHAT IS THE FAMILY’S WATER SUPPLY? (Please circle) Well or Public system or Bottled/distilled

HOW OFTEN ARE YOUR CHILD’S TEETH BRUSHED PER DAY? (Please circle) ONCE or TWICE or AFTER EACH MEAL or NONE



WHAT TYPE OF TOOTHPASTE DOES YOUR CHILD USE? ______________________________________ DO YOU HELP YOUR CHILD FLOSS DAILY? Yes or No



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