Patient Information. Child s Name Birthdate Gender M F. Nickname SS# Responsible Party Name Relationship

Transcription

1 Patient Infrmatin Date Child s Name Birthdate Gender M F Nickname SS# Respnsible Party Name Relatinship Address, address Hme Phne Cell Phne Wrk Phne Name f Schl Hbbies Whm may we thank fr referring yu t ur Orthdntic Practice? Medical Histry Physicians Name: Phne Number Has yur child been hspitalized r had a majr peratin? Yes N If Yes: Has yur child ever had a serius head r neck injury? Yes N If Yes: Is yur child taking any medicatins, pills r drugs Yes N If Yes: Des yur child take, r have taken Phen-Fen r Redux? Yes N Was yur child brn prematurely/experienced cmplicatins at birth? Yes N Is yur child allergic t any medicatins? Yes N If yes, explain Des yur child have any ther allergies? Yes N If yes, explain Des yur child require antibitics befre dental treatment? Yes N Other Des yur child have r has had any f the fllwing? AIDS/HIV Psitive Yes N Hemphilia Yes N Anaphylaxis Yes N High Bld Pressure Yes N Anemia Yes N Hives r rash Yes N Angina Yes N Hypglycemia Yes N Artificial Jint Yes N Kidney Prblems Yes N Asthma Yes N Leukemia Yes N Bld Transfusin Yes N Liver Disease Yes N Bld Disease Yes N Lung Disease Yes N Breathing Prblem Yes N Rheumatic Fever Yes N Cancer Yes N Sexually Transmitted Disease Yes N Cld Sres/Fever Blisters Yes N Sickle Cell Disease Yes N Cngenital Heart Disrder Yes N Sickle Cell Trait Yes N Diabetes Yes N Sleep Apnea Yes N Drug Addictin Yes N Strep Thrat Yes N Epilepsy r Seizures Yes N Tnsillitis Yes N Excessive Bleeding Yes N Fainting/Dizziness Yes N Dentist Ntes Glaucma Yes N Heart Murmur Yes N Are there any ther disabilities, handicaps r any medical prblems that we need t be aware f?

2 Dental Histry Previus Dentist Phne Number Date f last dental visit? Has yur child had difficulty with previus dental visits? If yes, Please explain Hw ften des yur child brush? Hw ften des yur child flss? Is yur child s water fluridated? Yes N Des yur child suck thumb/finger Yes N Des yur child Bite/Chew nails? Yes N Des yur child grind teeth? Yes N Des yur child clench jaws? Yes N Are yu interested in braces? Yes N Has the patient begun Puberty, and/r Menstruatin (Perid)? If s, at what age did this begin? What are sme f the main cncerns that yu wuld like the rthdntics t accmplish? Has the patient ever been evaluated fr rthdntic treatment? If s where? Have the patient s tnsils r adenids been remved? If s, when and by what dctr? Des the patient have speech prblems? If yes, please explain. T yur knwledge, is the patient missing r extra permanent teeth? Yes r N Has the Patient ever had an injury t: (select all that apply) Teeth Muth Chin Primary Insurance Insured s Name Relatinship Birthdate SS# Emplyer Occupatin Insurance Cmpany Grup # Member ID # Insurance Cmpany Address Insurance Cmpany Phne # Secndary Insurance Insured s Name Relatinship Birthdate SS# Emplyer Occupatin Insurance Cmpany Grup # Member ID # Insurance Cmpany Address Insurance Cmpany Phne #

3 Emergency Cntact In the event f an emergency, whm shuld we cntact ther than yurself? Relatinship Phne # Authrizatin & Release T the best f my knwledge, the questins n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my child s health. It is my respnsibility t infrm the dental ffice f any changes in my child s medical status. I als authrize the dental staff t perfrm necessary dental services my child may need. I als authrize the Dentist t release any infrmatin including the diagnsis and the recrds f treatment r examinatin rendered t my child during the perid f such care t third party payers and/r ther health practitiners. I authrize and request my insurance carrier t pay directly t the Dentist r Dentist grup insurance benefits therwise payable t me. I understand that my insurance carrier may pay less than the actual bill fr services. I agree t be respnsible fr payment f all services rendered n my behalf f my dependents. Signature f patient (r parent/guardian if minr) Date Signature f Dentist Date

4 Office Plicies fr Summerville Pediatric Dentistry and Orthdntics Appintment Plicy Yur child is unique and special t us, and appintment times are reserved exclusively fr each patient. Out f respect t yu and yur busy schedule, we reserve this specific time slt fr yur child s care and make every effrt t see them at that appinted time. We appreciate yur prmptness and ask that yu nt change yur appintment unless abslutely necessary. If yu d need t change an appintment, we ask that yu give us at least 48 hurs ntice s that we may make the time slt available t anther patient. We realize that unexpected things can happen but ask fr yur assistance with this regard. Financial Plicy A missed appintment fee f $25 will be applied t yur accunt with less than 24 hurs ntice f cancellatin. Repeated failure t keep yur appintments withut ntice may result in ur ffice discntinuing treatment fr yur children. Initials In the event that yur accunt is sent t cllectins fr nn-payment yu will be respnsible fr that amunt plus any fees that the cllectin agency charges ur ffice t cllect. Initials All fees fr rthdntic dental services are expected t be paid at the time f treatment. Fr yur cnvenience, we accept Care Credit, Visa, MasterCard, Cash and persnal checks. Dental Insurance We are glad t assist yu in btaining the maximum benefit frm yur dental insurance plan. Once yur cverage has been verified, we will accept assignment f payment frm yur insurance cmpany. Please knw that insurance will nt guarantee payments therefre, any amunt that they d nt pay will be yur respnsibility. Mst plans nly cver a prtin f the dental fee, which means yu will be respnsible fr yur deductible and the estimated c-payment. Yur c-payment is expected t be paid at the time f treatment. Fr yur cnvenience, ur ffice will gladly prcess yur insurance n yur behalf, understanding that the agreement yu have with yur insurance cmpany is between yu and them. Therefre, yu are respnsible fr any claims which remain utstanding after 60 days, and a finance charge may be applied t any balance due after this time. Payment will be expected n any such claims, and n further attempt will be made by ur ffice t cllect frm the insurance cmpany in this event. The parent r guardian wh brings the child t the appintment will be respnsible fr payment in full. All statements will be sent t this individual. We will nt bill a third party ther than insurance cmpanies. If yu have any questins regarding this plicy, please speak with smene frm ur ffice prir t treatment. We will nt alter financial arrangements nce treatment has been started. I have read the abve financial plicy and understand my bligatin t Summerville Pediatric Dentistry and Orthdntics. Please print child(ren's) name(s)

5 (Respnsible party signature) (DATE) Acknwledge f Statement f Privacy I acknwledge that a cpy f the Statement f Privacy Practices fr the ffice f Summerville Pediatric Dentistry and Orthdntics is available t me. The Statement f Privacy Practices describes the types f uses and disclsures f my prtected health infrmatin that might ccur in my treatment, payment fr services, r in the perfrmance f ffice health care peratins. The Statement f Privacy Practices is als psted in the facility. Summerville Pediatric Dentistry and Orthdntics reserves the right t change the privacy practices that are described in the Statement f Privacy Practices. A cpy f the revised Statement f Privacy Practices will be available upn request and will be psted in the facility. I give my permissin t Summerville Pediatric Dentistry and Orthdntics t use my and/r my child s picture n their website fr educatinal purpses. ADDITIONAL DISCLOSURE AUTHORITY In additin t the allwable disclsures described in the Statement f Privacy Practices, I hereby specifically authrize disclsure f my prtected health care infrmatin t the persns indicated belw. ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (PLEASE SPECIFY): YES NO Dr. Katie Bullwinkel, DMD, MS 405 West 5th Nrth St. Summerville, SC (843)