Welcome to The Kids Dentist NEW PATIENT FORMS

Transcription

1 TODAY S DATE Welcme t The Kids Dentist NEW PATIENT FORMS CHILD S FIRST NAME MI LAST NAME PREFERRED NAME: MALE FEMALE DATE OF BIRTH - - AGE ADDRESS CITY STATE ZIP PLEASE LIST IN ORDER THE BEST NUMBERS TO REACH YOU REGARDING YOUR CHILD S DENTAL APPOINTMENTS: PHONE #1 - - CELL HOME WORK PHONE #2 - - CELL HOME WORK PHONE #3 - - CELL HOME WORK CAN YOU RECEIVE TEXT MESSAGES ON YOUR CELL PHONE? YES NO HOW DID YOU HEAR ABOUT US? FATHER S/GUARDIAN S FULL NAME DOB MOTHER S/GUARDIAN S FULL NAME DOB PERSON RESPONSIBLE FOR MAKING DENTAL APPOINTMENTS AND FINANCIAL ARRANGEMENTS OTHER CHILDREN IN FAMILY (NAMES AND AGES) AUTHORIZATION I authrize The Kids Dentist t release any and all medical r dental infrmatin fr evaluatin, treatment, and any anticipated care. I understand that I am respnsible fr any and all charges (including cllectin fees). I understand that the estimated patient prtin is due at the time that services are rendered, unless ther arrangements have been made fr payment. I als understand that any treatment estimate that is given t me is dne in gd faith and I understand that my insurance may nt pay the amunts estimated by The Kids Dentist. I understand that I am respnsible fr knwledge f my insurance prgram and the limitatins f it. I have read this authrizatin and understand its cntents. SIGNATURE DATE RELATIONSHIP TO PATIENT

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3 Health Histry Frm GENERAL INFORMATION Patient Name DOB Weight Parent/ Guardian filling ut frm Describe child s temperament Is yur child adpted? YES NO D they knw? YES NO Is this a fster child? YES NO ALL PATIENTS: N N N DENTAL INFORMATION NEW PATIENTS ONLY: Name f previus dentist Phne # Date f last dental exam Cleaning Xrays Is there a particular cncern yu wuld like examined tday? Hass yur child had any negative dental r medical experiences? Is yur child currently taking fluride drps/tablets? N YES NO If yes, hw much/when Des yur child drink water frm the tap? YES NO Bttled Water? YES NO Des yur child have, r have they had any f the fllwing? Please check all that apply TMJ, painful r lcking jaw Nursing r bttle feeding at night Thumb sucking/ pacifier Yes N Grinding r clenching f teeth Tngue thrust Muth breather, nail biting MEDICAL INFORMATION Child s Physician Phne # Date f last exam Are yur child s immunizatins up t date? FEMALE PATIENTS: Is there any chance yu might be pregnant? N YES NO Are yu taking birth cntrl pills? Yes YES NO Has yur child ever been hspitalized? NYES NO Injuries/ surgeries Date Des yur child have any allergies r reactins (aspirin/pain medicatins, fd, antibitics, latex, preservatives/flavrings, etc)? YES NO Any medicatin taken n a regular basis (prescriptin, ver the cunter, vitamins, etc.)? Has yur child ever had r des he/she nw have any f the fllwing diseases/cnditins? Please check all that apply. Heart disease, murmurs, r rheumatic fever Lw r high bld pressure Kidneys, Endcrine, Liver (hepatitis), GI, Thyrid Cancer, tumrs, ther grwths If yes, radiatin r chemtherapy Date Epilepsy, seizures, r fainting Cngenital birth defects Diabetes, arthritis Asthma If yes, treatment Other breathing prblems/ diseases f lung (TB) Bleeding prblems r diseases f the bld Bld transfusins? Date Sinusitis, seasnal allergies Cld sre, canker sres Venereal r ther serius infectins Prblems with visin r hearing Fever, sre thrat/tnsils, ear aches/infectins Frequent/recurrent headaches r migraines Dietary restrictins Childhd diseases Immunlgical prblems r diseases (Leukemia, AIDS/HIV) Tbacc use (any frm) Chemical dependencies Emtinal prblems Learning r behaviral prblems * Develpmental delay/ mental challenges * Autism spectrum r sensry issues * * If yu answered yes t the last 3 questins, please fill ut the Supplemental Health Histry frm Are there any ther cnditins r anything else we shuld knw abut yur child? Parent Signature Date Prvider Signature Date Rev 4/1/15

4 INSURANCE INFORMATION DO YOU HAVE DENTAL INSURANCE? YES NO If yes, please fill ut the sectin belw PRIMARY SUBSCRIBER S NAME DATE OF BIRTH SS# ID NUMBER (IF YOUR INSURANCE DOES NOT USE SS#) EMPLOYER WORK NUMBER DENTAL INSURANCE NAME AND CLAIMS ADDRESS GROUP NUMBER INSURANCE PHONE NUMBER EFFECTIVE DATE DO YOU HAVE SECONDARY DENTAL INSURANCE? YES NO If yes, please fill ut the sectin belw SECONDARY SUBSCRIBER S NAME DATE OF BIRTH SS# ID NUMBER (IF YOUR INSURANCE DOES NOT USE SS#) EMPLOYER WORK NUMBER DENTAL INSURANCE NAME AND CLAIMS ADDRESS GROUP NUMBER INSURANCE PHONE NUMBER EFFECTIVE DATE *** PLEASE KEEP IN MIND THAT TO BILL YOUR INSURANCE CORRECTLY WE NEED ACCURATE, UP TO DATE INFORMATION. PLEASE HAVE YOUR CARD AVAILABLE SO WE CAN MAKE A COPY FOR YOUR CHILD S FILE. *** AUTHORIZATION I UNDERSTAND THAT I AM RESPONSIBLE FOR KNOWING MY INSURANCE PLAN PROVISIONS AND LIMITATIONS AND THAT ANY INFORMATION I GIVE WILL BE USED TO BILL MY INSURANCE FOR TREATMENT RENDERED IN THE OFFICE. I UNDERSTAND THAT THE KIDS DENTIST MAY NOT BE A PREFERRED PROVIDER WITH MY INSURANCE. I ALSO UNDERSTAND THAT EVEN IF I HAVE INSURANCE, THE KIDS DENTIST MAY ASK FOR THE PORTION THAT MY INSURANCE DOES NOT COVER AT THE TIME SERVICES ARE RENDERED, AND THAT I AM ULTIMATELY RESPONSIBLE FOR MY ACCOUNT. SIGNATURE DATE Rev 4/1/15

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