2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)

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1 2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803) Welcome to our practice! Please carefully complete this form so that we may better serve you. If you have any questions, we will be happy to assist you. We look forward to helping you maintain your child s dental health. PATIENT INFORMATION 1. Tell us about your child Full Name:_ Preferred Name:_ Male: Female: Age:_ of Birth: Interest/Hobbies/Pets:_ Address: City: State:_ Zip:_ Home Phone:_ School: Grade: Name(s) and Age(s) of Sibling(s): How did you hear about our office?_ 2. Parent/Guardian Information ( ) Mother ( ) Father ( ) Step Mother ( ) Step Father ( ) Guardian ( ) Other: Name:_ Preferred Name: of Birth: Address: City: State:_ Zip:_ Home Phone: Cellular Phone: Employer: Occupation: Work Phone: _ Is this person legally responsible for the health care decisions for the above patient? ( ) Yes ( ) No 3. Parent/Guardian Information ( ) Mother ( ) Father ( ) Step Mother ( ) Step Father ( ) Guardian ( ) Other: Name:_ Preferred Name: of Birth: Address: City: State:_ Zip:_ Home Phone: Cellular Phone: Employer: Occupation: Work Phone: _ Is this person legally responsible for the health care decisions for the above patient? ( ) Yes ( ) No List anyone you do not want patient information released to: List anyone who may accompany your child to an appointment and has permission to make decisions concerning their dental treatment: _

2 Patient Name: of Birth: 4. Electronic Communications I understand the confidentiality of electronic communications ( , text, etc.) cannot be guaranteed and Rock Hill Pediatric Dentistry is not responsible for the confidentiality or security of any message sent to or by me. If any of my contact information changes or at any time I wish to terminate this consent, I agree to notify Rock Hill Pediatric Dentistry in writing or in person. _ I authorize Rock Hill Pediatric Dentistry to contact me via electronic media. _ I do not authorize Rock Hill Pediatric Dentistry to contact me via electronic media. 5. Dental Insurance Information (If Applicable) Primary Insurance Person Who Carries Insurance: of Birth:_ SS#: : Employer: Insurance Company Name: Insurance Company Address:_ City:_ State: Zip: Phone:_ Group#: Policy#: Member ID#: Secondary Insurance Person Who Carries Insurance: of Birth:_ SS#: : Employer: Insurance Company Name: Insurance Company Address:_ City:_ State: Zip: Phone:_ Group#: Policy#: Member ID#: I certify that my dependent(s) is covered by insurance with company _ and I assign directly to Rock Hill Pediatric Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Rock Hill Pediatric Dentistry may use and disclose my child s health care information to the above named insurance company and their agents for the purpose of obtaining payment of services and determining benefits or the benefits for related services. This assignment will remain in effect until I cancel it in writing. Rock Hill Pediatric Dentistry s Notice of Privacy Practices is available for review and I am aware that I am entitled to a copy upon request.

3 Patient Name: of Birth: DENTAL HISTORY 1. What is the reason for today s visit? 2. Is this your child s first visit? Yes No If No, previous Dentist? Were x-rays taken? Yes No If Yes, date of most recent x-rays? 3. Does your child brush daily? Yes No Does your child floss daily? Yes No 4. Has your child had fluoride in any of the following forms? Fluoride tablets? Yes No Professional topical application? Yes No What is your water source? City Water Well Water 5. Does your child snack frequently? Yes No If Yes, describe snacks:_ Does your child drink soda or juice? Yes No If Yes, how often? 6. Have your child s teeth, mouth, and/or head ever been injured? Yes No Describe injury: When and what age? Which teeth were injured? Was treatment provided? Yes No If Yes, describe: 7. Does your child have any of the following habits? Bottle when sleeping at nighttime or naptime? Yes No If Yes, what beverage? Thumb or finger sucking? Yes No When was habit discontinued?_ Pacifier? Yes No When was pacifier discontinued? Mouth breathing? Yes No Snoring? Yes No Grinding of teeth? Yes No Nail biting? Yes No 8. When was nursing/bottle discontinued? 9. Has your child seen an orthodontist? Yes No If Yes, Orthodontist name:_ Is your child currently in braces? Yes No If Yes, date started: Currently, which phase? Phase I Phase II 10. Is there anything else you would like to tell us regarding your child s dental health?

4 Patient Name: of Birth: MEDICAL HISTORY Name of Pediatrician: Office phone:_ Address:_ City: State: Zip: Were there any difficulties during the pregnancy/delivery of your child? Yes No If Yes, please describe: Has your child been hospitalized since birth? Yes No If Yes, please describe: Does your child have any history of the following medical concerns? If any checked, please describe further: Has your child had any allergic reactions to the following? Medications? Yes No If Yes, please describe?_ Latex? Yes No If Yes, please describe?_ Foods? Yes No If Yes, please describe?_ Other? Yes No If Yes, please describe?_

5 Patient Name: of Birth: Is your child currently taking any medications? Drug How much? How often? Reason Have you ever been told your child requires antibiotic prophylaxis for dental treatment due to a medical condition (e.g., heart condition)? Yes No If Yes, what medical condition? Physician following medical condition (e.g., Cardiologist)? Address:_ City: State: Zip: Office Phone:_ I affirm that all of the above personal and health information I have given is correct to the best of my knowledge. The above information will be held in the strictest confidence. I understand that it is my responsibility to inform Rock Hill Pediatric Dentistry s dental staff of any personal or health information changes. I further understand that this consent will remain in effect until such time that I choose it to be terminated. CONSENT FOR TREATMENT I am the parent, guardian, or personal representative of the patient and there are no court orders now in effect that prevent me from signing this consent. I do hereby request and authorize Dr. Jonathan M. Mitchell and his staff to perform any necessary dental services including but not limited to comprehensive examinations, cleanings, x-rays and photographs as necessary for diagnostic purposes, any necessary treatment, and the administration of anesthetics that are deemed advisable by Dr. Mitchell, even in the event I am not present when treatment is rendered. I understand that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Mitchell will provide an environment that will help children learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments, and using variable voice tones. I will be responsible for any charges incurred for my child for dental treatment.

6 FINANCIAL POLICY We appreciate you choosing Rock Hill Pediatric Dentistry for your child s dental health needs. Please familiarize yourself with the following information regarding financial obligations. If you have any questions regarding our financial policy, please ask the administrative staff for assistance. Fees incurred are due in full when services are rendered. Payments may be made by the following options: Cash, Money Orders, Bank Issued Checks, MasterCard, Visa, and Discover. We also accept dental insurance and as a courtesy will file your insurance for you. We are a participating provider with most major insurance plans. Please contact your insurance company for verification of dental benefits. Some insurance companies recommend a pre-treatment authorization for the dental treatment to be provided and fees to be incurred prior to determining their benefits to you. We will attempt to estimate any out of pocket expenses prior to your visit to our office. Please be prepared for any deductible, co-pay, or other expenses at the time of service. If, for any reason, your insurance company does not respond with financial payment within 45 days post treatment, the balance is due and payable in full immediately by the parent/legal guardian financially responsible. The parent/legal guardian is responsible for payment of all patient accounts. We do not get involved in custody and/or financial disputes, which may or may not involve court orders. I have read and understand the financial policies of Rock Hill Pediatric Dentistry. In the event of default payment, I promise to pay any legal interest on the balance due, together with any collection costs. Collection fees will equal 50% of the amount turned over for collection. Reasonable attorney fees incurred to effect collection of the account or future outstanding accounts will be the responsibility of the parent/legal guardian. APPOINTMENT POLICY Rock Hill Pediatric Dentistry reserves a specific time for your child according to their treatment needs and level of cooperation. We make every effort to see your child at their appointed time. Inadvertent delays, such as emergencies and unforeseen patient treatment problems, may arise causing schedule changes. Should your child s appointment time be delayed, please accept our apology. Your patience is very much appreciated under these circumstances. If at all possible, please arrive 5 to 10 minutes prior to your child s scheduled appointment. This will allow time to complete any necessary paperwork. If you arrive 15 minutes beyond your appointment time, you may be asked to reschedule for the next available appointment time. As a courtesy, our office will attempt to contact you to confirm your child s appointment; however, we ask that you assume responsibility for your child s appointed time. If you need to reschedule an appointment, we ask that you provide our office with a 24-hour notice so that we may extend the appointment time to another patient. Multiple (2) broken/missed appointments without prior cancellation notice may be subject to dismissal from the practice. If at any time you have questions concerning our appointment policy, please ask our office team for assistance. We appreciate you entrusting your child s dental health to us!

7 Privacy Practices (HIPAA) Acknowledgement of Receipt of Notice of Privacy Practices You May Refuse To Sign This Acknowledgement We use the information that you provide for appointment reminders and to contact you regarding your appointments and care. By signing below, I _ acknowledge that I have read and understand Rock Hill Pediatric Dentistry s Notice of Privacy Practices, which is posted on Rock Hill Pediatric Dentistry s website and is also available at the check-in desk. I also have been given the opportunity to receive a copy. I authorize communication via voice mail: Yes No I authorize communication via Yes No I authorize communication via text message: Yes No Please list any persons to whom your protected health information can be disclosed (Example guardian, parent, grandparent etc.): Name: _ Phone #: Relationship: _ Name: _ Phone #: Relationship: _ By signing below, I authorize the release of medical/dental information to my primary care and/or referring physician, to medical/dental consultants if needed, and as necessary to process insurance claims, insurance applications, and prescriptions. _ : _ Relationship: _ Signature of patient, parent or guardian ***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 acknowledgement Other (Please specify): _ Prepared by: Signature: : _

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