1. Tell Us About the Patient. 2. Legal Guardian #1 Information. Child s Name Last. Preferred name. Grade. Patient s Age. School. Patient s Birth Date
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- Ralph Shields
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1 1. Tell Us About the Patient Child s Name Preferred name Male Grade School Patient s Birth Date Patient s Age Patient s Home Address City State Patient s Home ( Zip Siblings that we treat? 2. Legal Guardian #1 Information Name Employer Cell # ( Home# ( Work # ( DL# Appointment reminders via text message? reminders? Are you the responsible party? Female
2 3. Legal Guardian #2 Information Name Employer ( Home# ( Work # ( Cell # DL# Appointment reminders via text message? reminders? 4. Who is accompanying the patient today? Name Do you have legal custody of this patient? 5. How did you first hear about us? Google Facebook Online Reviews Friend Family Drive by Walk-in Foster Agency Austin Mom s Blog Insurance Post Card Mail Marketing Event Other (Please specify
3 6. Primary Dental Insurance Insurance Co. Name Insurance Co. Address City Ins. Co. Phone # ( State Zip Group # IDPolicy # Policy Owner s Name Policy Owner s Employer 7. Secondary Dental Insurance Insurance Co. Name Insurance Co. Address City Ins. Co. Phone # ( State Zip Group # IDPolicy # Policy Owner s Name Policy Owner s Employer
4 8. Dental History Any previous injuries to the teeth, face, or mouth? If yes, please explain: What is the reason for your visit today? Please check if the patient has had any of the following problems: Thumb Finger Sucking Nail Biting Ice Chewing Lip Sucking Biting Tongue Thrust Mouth Breathing Frequent Snoring Teeth Grinding Tonsils Removed Adenoids Removed Bad Breath Discolored Teeth Tooth Ache Bleeding Gums Sensitive to Sweets Sensitive to HotCold Has the patient ever had pain in the jaw joints(s (TMJTMD? Has the patient been referred for orthodontics (braces before? Has the patient ever had orthodontic treatment before? Does the patient have any missing teeth? Does the patient have any pending dental treatment that you know of? If yes, please explain Is the patient s water fluoridated?
5 Is the patient taking fluoride supplements? Does the patient brush their teeth daily? Does the patient floss their teeth daily? Has the patient ever taken biphosphonates, including: (Check all that apply Fosamax Didronel Aredia Zometa Boniva Actonel Skelid Patient s Physician Phone#( Is the patient currently under the care of a physician? Please rate the patient s current physical health Good Fair Poor
6 9. Health History Has the patient ever had any of the following conditions? Allergies: Seasonal Allergy: Food Allergies to any Drug Allergy: Latex Allergy: Nickel A ADHD Abnormal Excessive Bleeding Anemia Asthma Handicaps Disabilities Hearing Impairment Hepatitis Heart Disease Murmur Autism Cancer Gastro Intestinal Issues Rheumatic Scarlet Fever Diabetes Frequent Headaches Epilepsy Convulsions HIV+ AIDS Kidney Liver Conditions Respiratory Problems Nervous Disorder Tuberculosis Birth Defects Fainting Pre-Med - Clind Pre-Med - Amox Pre-Med - Other Hemophilia Blood Disorders High Low Blood Pressure Any Hospital Stays Any Operations Pregnancy (Waiver from Physician required for x-rays Please elaborate on anything checked above: Please list all drugs the patient is currently taking: Please list all drugs the patient is allergic to: OFFICE USE ONLY- DOCTOR INDIVIDUAL SIGNATURE
7 10. Please list authorized persons with whom we may discuss your Protected Health Information (PHI in addition to custodial parents and guardians: May bring to appointments May bring to appointments May bring to appointments May bring to appointments Cancellations We understand that things come up. Should you have a change in schedule, we kindly ask that you give us 48 hours notice. Consent for Services As a condition of treatment by this office, payment is due at the time services are rendered for estimated guarantor portion. As a courtesy, Lone Star Pediatric Dental & Braces will help prepare the patient s insurance forms or assist in making collections from the insurance companies and will credit any collections to the patient s account. However, in the event that there is a remaining balance, after insurace has paid, the patient is responsible for the remaining account balance. I understand that treatment plans are honored for a period of three months from the date of the patient examination, provided that there have been no changes in the original diagnosis. 11. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform Lone Star Pediatric Dental & Braces of any changes to the patient s medical status. If the office accepts my insurance, I am responsible for any co-payments, deductibles or any fees that my insurance does not cover. I consent to Lone Star Pediatric Dental & Braces submitting insurance claims on the behalf of the insurance policy holder, and allowing the provider to accept the assignment of benefits. We reserve the right to charge a $25 NSF fee in the event of any dishonored check for any reason. LSPD&B may enforce that all subsequent payments be paid in cash or certified funds thereafter. By signing, I agree to the conditions and terms above. Patient or Legally Authorized Individual Signature Date: Time: Witness Signature Date: Print Patient s Full Name: Time:
Patient Information Patient Name:, Patient Last Name Patient First Name MI Preferred Male Female Family Status: Married Single Child
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Patient Information. Health Information
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❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
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PERSONAL INFORMATION
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Dell A. Goodrick, DDS, FAGD
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Patient Registration
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PATIENT INFORMATION Name: E-mail: Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / Social Security Number: - - Driver s License #: RESPONSIBLE PARTY INFORMATION
Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
18121 E Hampden Ave, Unit E Aurora, CO
18121 E Hampden Ave, Unit E Aurora, CO 80013 303-848-4929 Patient Information Name: E-Mail Address: Male Female Gender: Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Home Address: Date of Birth: / /
Just for Kids Pediatric Dentistry, Ltd. Patient Information
Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
YOUR CHILD'S PERSONAL INFORMATION. RESPONSIBLE PARTY (Person responsible for Child's Account)
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Anthem Hills Dental PATIENT INFORMATION
PATIENT INFORMATION Patient Name DOB Date Address City ST Zip Preferred Contact # Home # Cell # E-mail _ SSN Marital Status: S M Other Employer Type of Work Work # Business Address_ City ST Zip Emergency
PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address: