Patient Information

Download 85.34 Kb.
Date conversion06.12.2016
Size85.34 Kb.

Patient Information

Patient Name: ____________________________________________________ Date: ______________

Last First MI

Patient Date of Birth: ________________________________ Male Female Age of Child_________

Address: _________________________________________________________________________________

Street Apartment #


City State Zip Code

Guardian Name: __________________________________________________________________________

Last First MI

Phone (Home): ________________________ (Work): _______________________ (Cell):____________________

Email Address: _______________________________________________________________________________

Name of Pediatrician Phone Number

Health Information

Has patient ever had any of the following? Please check those that apply:

AIDS/HIV Head injuries Nervous Disorders Stomach Problems

ADD/ADHD Heart Disease Pacemaker Stroke

Allergies (seasonal) Heart Murmur Radiation Treatment Tuberculosis

Anemia Hemophilia Respiratory Problems Venereal Disease

Asthma Hepatitis Rheumatic Fever Codeine Allergy

Autism Jaundice Seizure ________ Food Allergy

Blood Disease Kidney Disease Sickle Cell Disease Latex Allergy

Cancer Liver Disease Sickle Cell Trait Penicillin Allergy

Cerebral Palsy Mental Disorders Sinus Problems Other

Diabetes Mental Retardation Skin Disorder(s) ________________

Has the above mentioned patient ever had any complications following dental treatment? Yes No

If yes, please explain ____________________________________________________________

Has the above mentioned patient been admitted to a hospital or needed emergency care in the past two years?

Yes No If yes, please explain __________________________________________________

Is the above mentioned patient now under the care of a physician? Yes No

If yes, please explain ____________________________________________________________

Name of Physician _____________________________________________________________________

Is the patient currently taking any medications? Yes No

If yes, please explain ____________________________________________________________

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If patient ever has any change in health, I will inform the doctors at the next appointment without fail.
________________________________________________________________ ______________________________

Signature of parent or guardian Date
Whom may we thank for referring you (i.e. person, institution, and website)? ________________________________________________

Type of referral: Patient/Friend/Relative Yellow Pages Website School Work Facebook Others ___________________
Medical Information

Yes No Are your child’s immunizations up to date?

Yes No Is your child taking any medications at this time? If yes, please explain:


Yes No Has your child ever had a problem with his or her speech, sight, hearing, or learning disabilities?

If yes, please explain: _______________________________________________

Yes No Has your child ever received an injury or had a fall to the head, jaws, mouth, or teeth?

If yes, please explain: ___________________________________________

Dental History

Yes No Is this your child’s first visit to a dentist? If not, date of last visit: _____________________

Dentist name: _________________________________________________________________

When was your child’s last dental x-rays taken? ______________________________

Yes No Has your child had a toothache recently?

Yes No Does your child brush his/her teeth?

Yes No Do you assist with brushing?

Yes No Is your child presently using a nursing bottle? Age discontinued _____________

Yes No Does your child have a history of thumb sucking? ___ Finger sucking? ___ Pacifier use?

____ Nail biting? _____

Yes No Does your child snore at night? ___ Mouth breathe? ____ Grit or grind their teeth?_____

Other habits? ______________________________________

Yes No Do you live in a fluoridated water area? Don’t know ____________

Yes No Does your child play organized sports? Type? _______________________________

Yes No Has your child had a frightening or painful dental experience?

What have you told your child about today’s dental appointment?


Yes No Has your child had any problems with previous dental treatment?

If yes, please explain: ____________________________________________________

Yes No Does your child have a dental condition about which you are especially concerned?

If yes, please explain: ____________________________________________________

Yes No Has your daughter began menstruation?

Simply Children’s Dentistry, Inc.

Notice and Consent Form
Patient’s Name: ____________________________________________________

Parent/Guardian: ___________________________________________________
Simply Children’s Dentistry, Inc. wants you and your child’s visit to be both educational and enjoyable. Therefore, we request that you read this Notice and Consent Form carefully. This form is meant to provide information on some of the routine procedures we perform. If you do not have any questions or concerns we ask that you complete the form and sign the bottom of the page giving us your consent to perform the listed procedures if deemed necessary.

Please place an initial next to each paragraph indicating that you understand and consent to the procedure.

____ Consent to receive dental treatment. I consent and authorized Dr. Kamiti Harden and her employees to examine, clean and provide dental treatment for my child. I further consent and authorize the taking dental x-rays as may be considered necessary by Dr. Kamiti Harden to diagnose and/or treat my child. I will allow photographs to be taken of my child and/or child’s teeth for diagnostic and educational purposes.
____ Consent to receive Nitrous Oxide/Oxygen Sedation. I consent and authorize Dr. Kamiti Harden to use Nitrous Oxide (laughing gas) during treatment of my child. Nitrous Oxide/Oxygen sedation is generally safe and effective technique to reduce or eliminate anxiety and enhance effective communication. Its onset and recovery is rapid. Additionally, Nitrous Oxide aids in reducing pain and the gag reflex. Dr. Flowers uses nitrous oxide for all patients who she has to give an injection to. There is a fee associated with this procedure.
____ Consent to immobilization. I understand and agree that it may be necessary for Dr. Kamiti Harden to use a papoose board (hug blanket) during the dental procedure to prevent injury and enable her to safely provide the necessary treatment for my child. There is a fee associated with this procedure. This procedure is not covered by most insurance companies.

_____________________________________________________ Date _______________________________________

Parent/Guardian Signature

Responsible Party Information

Must be present with proper ID to be considered as the Responsible Party

Name: _______________________________________________________________________________

Male  Female Married Single Other _________________________________

Relationship to patient: ________________________________________________________________

Social Security #: __________________________ Birth Date: _________________________________

Phone (Home): _________________________ (Work): ____________________ (Cell): ________________

Address: ____________________________________________________ Apt. # ______________________


City State Zip Code
Responsible Party’s Employment Information

Employer Name: _____________________________________ Occupation: ____________________________

Address: ___________________________________________________________________________________

Street City/State Zip Code Phone#

Commanding Officer: _______________________________________ Phone (Work): _______________________________
Insurance Information


Name of Insured: ____________________________________________________________________________

Last First MI

Birth Date: ________________________ ID# __________________________ Group# _______________________

Name of Insurance Plan: _______________________________________________________________________


Name of Insured: ____________________________________________________________________________

Last First MI

Birth Date: _____________________ ID# _______________________ Group# ___________________________

Name of Insurance Plan: _____________________________________________________________________

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility from each patient must be determined prior to treatment.

All emergency dental services or any dental services performed without previous financial arrangements must be paid in full before services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he/she is responsible for payment. This office will help prepare insurance forms and assist in collecting from insurance companies and will credit such collections to the patient’s account. However, this dental office cannot render services on the assumption that the charges will be paid by the insurance company. A service charge of 1.5% per month will be charged on the unpaid balance of all accounts exceeding 60 days.

In consideration for the services rendered to me, or at my request, I agree to pay the reasonable value of said services at the time treatment. I further agree that the reasonable value of said services shall be as billed unless objected to, within the time for payment thereof. I also agree that a waiver of any breach shall not constitute a waiver of any further term or condition. I agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

__________________________________________ Signature of Responsible Party Date______________________________

Office Financial Policy

  • I understand that I am responsible for all fees related to my dental care and treatment.

  • I understand that full payment for all dental treatment is to be paid at the time the treatment is rendered.

  • I understand that any and all account balances over 30days may incur a monthly interest charge and the maximum rate.

  • I understand that if a check, or other instrument, or any electronic authorization or debit sent or provided to Simply Children’s Dentistry, Inc. for payment is not honored upon first presentment, regardless of the reason, even if the check, instrument or electronic authorization is later honored, I will be charged the maximum allowable service charge of $30.

  • I understand that if my account is not timely paid, my account may be turned over to a collection agency. In addition to paying my balance, I agree to pay all reasonable attorney‘s fees, and/or court costs as well as collection fees of 25% of balance.

Broken And/Or Missed Appointments

Simply Children’s Dentistry, Inc. reserves the right to charge a $35.00 fee for any appointment not kept by the patient or broken without a 48hr advance notice. After two (2) broken or missed appointments, the dentist retains the right to discontinue elective treatment. Voicemail will not be sufficient form of breaking an appointment. You are required to speak to a representative.
Patients With Dental Insurance

  • I understand that my insurance policy is a contract between my insurance company and myself. Simply Children’s Dentistry, Inc. and its employees are not parties to my contract with my insurance.

  • I understand that I am ultimately responsible for any and all balances, even if my insurance company agrees to pay a balance and later does not pay.

  • I understand that I may be given the option of only paying my estimated portion (portion not covered by insurance) at the time of services. As a courtesy, the office will send my claim to my insurance company. If my insurance company fails to pay the balance, the balance is my responsibility and payment is due in full.

  • I understand that if my first visit is an emergency visit, I will be responsible for payment of services in full at the time of the visit. As a courtesy, Simply Children’s Dentistry, Inc. will provide to me the necessary documents to file to my insurance company for reimbursement.

For Patients With Insurance, Please Initial The Billing Option Of Your Choice

____ I will pay my total balance at the time of service and will seek reimbursement directly from my insurance company.

____ I will pay only my estimated portion at time of service and have my insurance pay the office. If my insurance company fails to pay the balance, it remains my responsibility and I must pay all amounts due. If this is my first visit and it is an emergency visit, I understand that payment for all services is due at time

I have read, understood and agree to the terms of the above stated policies.
_______________________________________________ __________________________________

Signature of Parent/Guardian Date

scd printready logo

Policy on Parental Presence
At Simply Children’s Dentistry our goal is to make you and your child’s visit as enjoyable, fun and comfortable as possible. It is very normal for children to be scared and apprehensive, and we are trained to handle this. We ask that when children are receiving treatment, that the parents remain in the waiting area, unless the parent fully understands the Silent Parent Policy. We have noticed that some children are more cooperative when no parent is present, while few are cooperative when the parent is present.
Some of the reasons for this policy are:

  • Parents often repeat and/or inject orders, becoming a barrier to development of the rapport between the doctor and the child.

  • The child often becomes confused and divides his/her attention between the parent and the doctor.

  • The doctor divides attention between the parent and the child and it is during this time when the doctor wants to focus totally on the needs of the child.

The doctor is fully aware that the parent can be a major asset in supporting and communication with a disabled child, or a young infant. While there are exceptions to every policy, those exceptions are left to the doctor’s discretion. Please remember that our number one goal is the safety and comfort level of your child. When and if the doctor feels that the parent can help calm the child during a procedure, the doctor will ask that the parent comes back. If it is your first visit, which is ALWAYS an examination, the parent is allowed to come back with the child. If two parents are present, we ask that only one come back with the child, and preferably the one that the child will be more cooperative with. For the safety of our patients & staff only the patient and 1 parent are allowed in the treatment rooms.

______________________________________________ _______________ _______________________________

Parent/Guardian Signature Date Doctor’s Signature

Appointment Policy

We are honored to have the opportunity to treat your child. We appreciate the trust you have placed in us. We strive to give each child the individual attention they deserve. In a sincere effort to acknowledge the importance of each parent’s time, and to remain on time ourselves, we ask that ensure that your child arrives on time for their appointment. This will allow us to see all scheduled patients in a timely and efficiently. When a patient is late or fails to keep their scheduled appointment, it affects all of the children and their parents that are scheduled that day.

If a patient is more than 15 minutes late, we may need to reschedule their appointment. If we are able to see your child, we cannot guarantee that all treatment will be completed. If a patient misses their appointment, they will be rescheduled once. If a second appointment is missed, the patient may be dismissed from our practice, or required to make a non-refundable deposit before scheduling another appointment.
If necessary, parents may cancel or change their appointment BEFORE 9:30 AM two business days before the appointment.
It is your responsibility to personally confirm your child’s appointment. We will make every effort to reach you to confirm. We will call you three business days prior to your child’s appointment
All Appointments may be changed or cancelled by 9:30 AM up to 2 business days BEFORE the appointment date. Additionally, all appointments must be CONFIRMED by 9:30 AM, two business days BEFORE the appointment date. An unconfirmed appointment will be moved off of our schedule to allow another child to be seen by our office.
We will make every effort to contact you by phone or email to CONFIRM your appointment.

Due to schedule demands, we can only accommodate 2 members per household per day. Thank you for your understanding.

We ask that you acknowledge our appointment policy by signing below.
_____________________________________ ________________________

Signature Date


Dear Parents:

In order to improve the chance of your child having a positive experience in our office, we are selective in our use of words. We try to avoid words that scare the child due to previous

experiences. Please support us by NOT USING negative words that are often used for dental care.

These include:


needle or shot


drill on tooth

pull or yank tooth

decay, cavity


tooth cleaning


rubber dam


Does it hurt?


sleepy juice


clean a tooth

wiggle a tooth out

sugar bug

count teeth

tickle teeth



magic air

Does it feel funny?

This will also help you understand your child’s description of the filling experience. Our intention is not to ”fool” the child it is to create an experience that is positive. We appreciate your cooperation in helping us build a good attitude for your child.




Dear Parents:

You may choose whether or not you accompany your child to his/her

treatment appointment. Although we sense that some children do better

without parents present, we are open to having you with your child.

If you choose to be present, we suggest the following guidelines to

improve chances of a positive outcome:

1. Allow us to prepare your child

2. Be supportive of the practice’s terminology

3. Please be a silent observer--support

your child with touches

A. This allows us to maintain communication with your child

B. Children will normally listen to their parents instead of us and

may not hear our guidance

C. You might give incorrect or misleading information

4. If asked to leave, be ready to immediately walk away

A. Many children will try to control the situation

B. “Acting out” is normal, but unacceptable during fillings

C. This is intended to “short circuit” the control attempt

D. We will continue to support your child at all times

These are very important ways that you can actively help in the

success of your child’s visit. We are confident that all will go well

and hope these guidelines will help prepare you with confidence for

the upcoming appointment.


Simply Children’s Family Dentistry, Inc.

Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of Simply Children’s Family Dentistry,

Inc.. I hereby authorize, as indicated by my signature below, Simply Children’s Family

Dentistry to use and to disclose my protected health information for any necessary clinical,

financial, and insurance purpose, as authorized in the Patient Consent form.

_________________________________ _________________________________

Print Name Address
_________________________________ ___________

Signature Date

Please check your preferred means of communication:

□ You may contact me at my home telephone number _____________________________

□ You may contact me on my mobile telephone number ____________________________

□ You may contact me on my work telephone number _____________________________

□ You may send me an unencrypted email/text message at: _________________________

□ Other __________________________________________________________________

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in

addition to custodial parents and legal guardians:

1. ______________________________________________ Date Added / Removed: __________

2. ______________________________________________ Date Added / Removed: __________

3. ______________________________________________ Date Added / Removed: __________

4. ______________________________________________ Date Added / Removed: __________

* * *

For Office Use Only:

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

□ Individual refused to sign

□ Communication barriers prohibited obtaining the acknowledgement

□ An emergency situation prevented us from obtaining the acknowledgement

□ Other (Please Specify) _____________________________________________

Staff Person Initials ___________

613 Stephenson Ave. Ste. 201, Savannah, Georgia 31405

Phone: 912-353-9993 /Fax: 912-353-9995/Email:

The database is protected by copyright © 2016
send message

    Main page