Welcome to our practice! We strive to make each of your child’s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their lifetime



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Welcome

to our practice! We strive to make each of your child’s visits

pleasant and comfortable. Our goal is to teach your child oral habits

which will help keep their smile beautiful for their lifetime.


Email_________________________

Child’s First ______________M.I.___

Last_______________

Preferred ______________ Sex ______

Date of Birth ______________ Age ____

SS#SIN ___________________

School _________________ Grade ____

Child’s Home Address_______________

_________________________________

City ______________________

State/Prov. ______________________

ZIP/P.C. _________________

Phone ________________





Your Child

First________________ M.I.___ Last_______________________

Home Phone____________________

Work Phone____________________

Cell Phone ____________________

SS#SIN#____________________

Date of Birth_______________

Employer____________________

Occupation____________________

DL#____________________





First________________ M.I.___ Last______________________

Home Phone___________________

Work Phone____________________

Cell Phone ____________________

SS#SIN#____________________

Date of Birth_______________

Employer____________________

Occupation____________________

DL#____________________







Father

Stepfather Guardian




Mother

Stepmother Guardian

[Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Text Box Tools tab to change the formatting of the pull quote text box.]










Responsible Party

First __________________ M.I. ____

Last ____________________

Relationship _______________

Address _________________________

_______________________________

Home Phone ___________________

Work Phone___________________ Ext.________

Cell Phone____________________


How did you hear about us? _______________________

Parent’s Marital Status

Single Divorced

Married Widowed

Separated

5
Insured’s name___________________ Relationship___________

Date of Birth______________ SS#SIN_______________ Employer________________

Ins. Company_________________ Group #_____________ ID#________________
Additional Insurance Insured’s Name_________________ Relationship____________

Date of Birth_______________ SS#SIN_________________ Employer___________________

Ins. Company__________________ Group#__________________ ID#______________

_____________________



Primary Dental Insurance






Child’s Habits
Health History


How often does your child brush? _______________
Your child’s overall health as well as any medications


How often does your child floss? ___________________

How often does your child floss? ___________________
which your child takes could have an important inter-


Date of last dental visit _____________________________

Date of last dental visit _____________________________
relationship with the dental care your child receives.


Previous Dentist _____________________________________

Previous Dentist _____________________________________
Please answer each of the following




Authorization and Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

X________________________________________

Signature of parent or parent/guardian if minor

____________________

Date

Child’s Physician _______________________________________

Physician’s Number _____________________________________

Child’s Date of Birth _____________________________________

Is your child’s water fluoridated? ............................ Yes No

Does your child take fluoride supplements? ............ Yes No

Clench Jaws ……………. Yes No

Grind teeth ………………………… Yes No

Chew Hard Objects (pencils, etc.)……… Yes No

Bite/Chew Nails …………………………………… Yes No

Suck/bite lips ………………………………..…………. Yes No

Suck Thumb/finger ………………………….….………. Yes No

Does your child:

Child’s Physician _______________________________________

Has your child had difficulty with previous visits? ________________

Has your child ever had sleep apnea or snore while sleeping? _______________

Has your child ever had any of the following:
Asthma Yes No Rheumatic Fever Yes No

Cancer Yes No Congenital Heart Defect Yes No

Hepatitis Yes No Handicaps/Disabilities Yes No

HIV/AIDS Yes No Convulsions/Epilepsy Yes No

Hemophilia Yes No Abnormal Bleeding Yes No

Diabetes Yes No Heart Murmur Yes No

Allergies Yes No ADHD/ADD Yes No

Autism Yes No

Previous Surgeries Yes No (if yes, what?)_______________________

Please explain any medical problems that your child has

_________________________________________________________

Please list any medications your child may be taking____________________________________________________ Please list any medications your child may be allergic to_______________________________________________________



Questions completely.

d:\brentwood pediatric dentistry\logo\brentwood-dentistry_logo.jpg

Authorization for Treatment
In my absence, I hereby authorize (Please list all people who will be allowed to bring your child to the office

for treatment) ____________________________________________________________________________

______________________to accompany (print child’s name) ______________________for necessary

preventative and/or restorative appointments to Brentwood Pediatric Dentistry, PLLC as deemed by

Dr. Ryan Cregger and his associate dentists as well as BPD staff. These procedures could include

photographs, x-rays, fluoride treatments, nitrous oxide, possibly even sedation medications. The

aforementioned person has my full permission to make decisions concerning treatment of my child,

both the day of the appointment and any future appointments. As witnessed by my signature,

I will indemnify and hold harmless Dr. Ryan Cregger and his associate dentists and BPD PLLC staff,

for all claims arising out of my consent for my child to be treated.


_________________________________________

Signature of Legal Guardian


_________________________________________

Print name of Parent or Legal Guardian


___________________________________

Date



Doctor Treatment Authorization
Thank you for choosing Brentwood Pediatric Dentistry as your child’s dental care

provider. Our main focus at Brentwood Pediatric Dentistry is to ensure that your child has

a positive dental experience.

Our doctors are uniquely trained to care for the oral health and dental development

of infants, children, adolescents, and special needs patients.

By signing below, I hereby authorize Dr. Ryan Cregger, Dr. John Stritikus, and Dr. Justin

Robbins and their associate dentists to perform any and all necessary preventative and/or

restorative procedures that they deem necessary, with the consent of the parent or legal

guardian. These procedures may include, but are not limited to photographs, x-rays,

fluoride treatments, fillings, extractions, crowns, the administering of nitrous oxide,

and/or sedation medications, and other dental procedures.

Should you have any reservations, please see the receptionist. Otherwise please

sign the below authorization.

_____________________________

Parent or Legal Guardian

____________________________

Print Name of Patient

___________________________

Date

95 Seaboard Lane, Ste. 102 Brentwood, TN 37027



Ph 615.377.3080 Fax 615.377.3088

Email: info@brentwoodpediatricdentistry.com

www.brentwoodpediatricdentistry.com

Brentwood Pediatric Dentistry

Your Privacy is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

(Minor)

I have received a copy of the Notice of Privacy Practices of Brentwood Pediatric Dentistry. I hereby authorize,

as indicated by my signature below, Brentwood Pediatric 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 at my mobile telephone number __________________________

You may contact me on my work telephone number ___________________________

You may send me an email at_______________________________________________

Other___________________________________________________________________
Please list authorized persons with whom we may discuss your Protected health Information (PHI) in addition to custodial and legal guardians:


  1. _____________________________________ Date Added/Removed:_______________

  2. _____________________________________ Date Added/Removed:_______________

  3. _____________________________________ Date Added/Removed:_______________

  4. _____________________________________ Date Added/Removed:_______________

  5. _____________________________________ 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) ______________________________________



Office Policy & Patient Consent for Minors

Thank you for choosing Brentwood Pediatric Dentistry, PLLC as your child’s dental care provider. Our dental health

team is committed to excellence in dental care in a friendly, comfortable environment. It is very important to us as

your dental care provider to utilize every means necessary to provide the best dental care possible. We ask that when

you have an appointment, please call and confirm the appointment to ensure that we will still have availability.

Unconfirmed appointments are not guaranteed and can be given away in the case if an emergency. However, confirmed appointments can be counted against you if the appointment is not kept or if we are not notified within 24 hours of the appointment. After 3 missed appointments, you may be asked to find another provider.


Insurance
Most procedures are covered by TennCare. Procedures not covered (or claims denied due to ineligibility) by TennCare

have to b paid by the parents and/or guardians. It is your responsibility to make certain your TennCare coverage is in

force before your appointment. At BPD PLLC, we are not “signed up” with all insurance companies. It is your

responsibility to make certain your insurance plan will pay for your visit. Of course we will be happy to assist you,

however, please understand your insurance is contracted between you and the insurance company. We are the third

party and have limited ability to act on your behalf. Upon signature of this policy & consent form, you authorize the

practice to release to staff, hospitals, health care service plans, insurance companies, self-insurers or the

representatives, any and all information, records, and radiographs about the patient’s medical history, services rendered,

or recommended treatment. You also authorize the practice to submit claims for payment for services rendered or

pre-authorizations necessary to your insurance company, on your behalf or the patient’s behalf with your name listed

as “signature on file” and assign to the practice the insurance benefits, providing assignment is accepted, you are

responsible for payment regardless of the coverage provided.

Any account not paid in full within 90 days will be subject to collection fees. The fees incurred will be the responsibility

of the parents and/or guardians. These fees may include, but are not limited to, returned check fees, attorney fees,

and court costs.
Clinical Consent

As the parent/legal guardian of the minor patients, I authorize Brentwood Pediatric Dentistry, PLLC to perform all

recommended treatment on the patient. I authorize the practice to take radiographs, study models, photos, and

other diagnostic aids or materials collectively (“diagnosed material”) as needed to make a thorough diagnosis.

I authorize that such diagnostic material may be released to third-party payers and/or other health professionals.

I authorize the practice to use my child’s photos and/or x-rays for educational and clinical presentations as the

practice deems appropriate. The patient’s confidential information will never be disclosed.
I have read the Patient Consent and agree to the terms and conditions herein.
Patient’s Name: ______________________________ D.O.B:____________________________

Signature of Parent/Guardian: ___________________ Date: _____________________________



Relationship to Patient: ________________________ Address: __________________________


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