Patient Safety and Privacy. Appointment Policy

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Isaac Wilkinson
5 years ago
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1 Patient Safety and Privacy For your comfort one adult is welcome, but not required to accompany your child to the treatment areas. We do encourage self independence to help promote the growth and development of your child. For safety and privacy of the other patients all other children, including children that are not scheduled at this appointment, are asked to remain in the reception room. Young children in the reception room will need a supervisory adult. Also, please refrain from bringing strollers into the treatment area as well, as they tend to block common pathways. Additionally, the use of cellular phones is prohibited in the treatment areas. The extra conversation carried on by others in the clinical area can be most distracting to children, preventing us from close, careful communication with each young patient. Thank you for your understanding and cooperation in these matters. Appointment Policy The scheduled appointment is reserved specifically for your child. Any change in this appointment affects many patients. If a cancellation is unavoidable, please call the office at least 24 hours in advance so that we may give that time to another patient. We strive to see all patients on time for their scheduled appointment. There are times when our schedule is delayed in order to accommodate an injured child or an emergency. Please accept our apology in advance should this occur during your appointment. We will do the exact same if your child is in need of emergency treatment. Please plan to arrive 10 minutes or more before your scheduled appointment. This will allow time to complete any additional paperwork and see your child on time. If you arrive minutes late for your appointment, you may be asked to reschedule for the next available appointment time. Again, please call at least 24 hours in advance if a cancellation is unavoidable so that we may give it to another patient. Broken or missed appointments affect many people. If two (2) broken/missed appointments occur or two (2) cancellations without 24-hours notice, our office reserves the right to NOT schedule any subsequent appointments. A parent/legal guardian (with official documentation) must be present during the initial examination and/or any treatment appointments. If at any time you have questions, please feel free to ask our staff or call our office. We are here to help any way we can. We appreciate you entrusting your child's dental health to us. Thank you! Signature Date

2 Consent for Treatment and Billing I give permission to Dogwood Pediatric Dentistry of Savannah to provide de nta l, counseling and ed ucational ser vices as well as any treatment related to those services to myself or the minor child(ren) named below. I understand that testing for blood borne disease (including HIV/AIDS) may be performed upon a patient without separate written consent in the event that a health care professional or employee of sustain a percutaneous, mucous membrane, open wound or occupational exposure to blood or bodily fluids. I give my permission to Dogwood Pediatric Dentistry of Savannah to bill my insurance carrier and if request provide any medical information to them. I also give my permission use my x-rays and photographs for display. As a condition of your treatment by this office, financial arrangement must be made in advance. All emergency dental services or dental services performed without previous financial arrangements must be paid for at the time services are rendered. Please review our financial policy for our convenient payment methods that we offer. As a courtesy to you we will file claims to your insurance carrier and assist in collecting. However, the balance on your account after filing is your responsibility regardless of your carrier's said coverage. A service charge of 1 ½% per month (18% annum) on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written arrangements are satisfied. I have read and understood the above conditions of treatment and billing and agree to their content. I sign it freely and voluntarily. Date Parent/Guardian of minor Relationship to minor Minor(s) Full Name:

3 TELL US ABOUT YOUR CHILD Patient Name: Date of Birth: 1. Is this your child s first dental visit? Y or N 1. Has the child ever had a serious/difficult problem with dental treatment? Y or N If yes, please explain: 2. Patient s physician: Phone #: Date of last physician visit: 3. Does your child have any of the following: Thumb/lip sucking Discolored Teeth Pacifier Teeth Sensitivity Toothache Jaw Pain Cavities Crooked Teeth Bumped/broken teeth Date: 4. Was your child bottle or breast fed? Age stopped? 5. Is your water fluoridated? Y or N 6. Does your child take fluoride supplements? Y or N 7. How did you hear about us? Another dentist, physician or clinic: Another patient or employee: Website Facebook TV Commercial Flyer or Postcard Insurance Drive /Fundraiser Other: **DO YOU WANT A FLUORIDE APPLICATION APPLIED TO YOUR CHILD S TEETH? YES NO Please list names of all persons with whom our staff may discuss your child s treatment and or other dental needs. Person Relationship Person filling out form: Signature of consent: Address: Relationship: Date:

4 Demographic Information Patient Date Name child would prefer to be called Birthday Sex Home Phone Home Address street city,state zip code Mother s/guardian Name DOB Mother s/guardian SSN Cell Phone Mother s Address Work Phone Mother s/guardian Employer Father s Name DOB Father s SSN Cell Phone Father s Address Work Phone Father s Employer Who has legal custody of the patient? Person responsible for payment of account Dental Insurance: Yes No Subscriber s Name Employer Insurance Company Claims Address Insurance phone Group No Secondary Dental Insurance: Yes No Subscriber s Name Employer Insurance Company Claims Address Insurance phone Group No

Consent to Publication and Release of Photographs I, the undersigned (or parent/legal guardian of),, hereby consent to the use of my/my child's photographs, which I have voluntarily allowed to be

5 Consent to Publication and Release of Photographs I, the undersigned (or parent/legal guardian of),, hereby consent to the use of my/my child's photographs, which I have voluntarily allowed to be taken and my child's name by Dogwood Pediatric Dentistry of Savannah for both commercial and non-commercial publication. I hereby waive any right to which I/our heirs be entitled by law to assert against the company on account of injuring to my/our reputation and hereby release the company from any and all liability on account of such injury. Further, I understand that by the execution of this agreement, I am relinquishing all my rights to such photographs and to any future compensation for publication, use or sale of the same. I also understand that the Company may sell and/or publish these photographs in any medium including, but not limited to, reproduction of the same in magazines, newspapers, , the Internet or worldwide web. I also consent to the Company copyrighting such photographs and enjoying all rights provided to copyright holders. I do not retain the right to view or approve such photographs prior to publication. Consented to this day of,20 _ by the undersigned. Parent/Guardian Name

6 Financial Statement I understand that I am responsible for the entire cost of treatment. I further understand that if it ever becomes necessary for this account to be turned over for collection, I am responsible for any collection and/or attorney fees. Insurance Statement I authorize the release of any information needed to process my child s insurance claims. I further understand that I am responsible for the entire cost of treatment regardless of insurance coverage or payments. I authorize payment of insurance benefits directly to the dentist otherwise payable to me. Disappointment Fee I understand it is my responsibility to give the doctor at least a 24 hour notice if I am unable to keep my child s appointment. In the event that I do not give the 24 hour notice or do not call and do not show up, the doctor reserves the right to charge a $50 cancellation fee. This will compensate for the time he had reserved to treat my child and was unable, due to lack of notice, to schedule another patient for treatment during that time. Authorization I hereby authorize and acknowledge that any scanned/electronic signatures are to be considered an original signature. Acknowledgement of Receipt of Privacy Practices Notice I hereby acknowledge that I have received or rejected Notice of Privacy Practices from the office of Dogwood Pediatric Dentistry of Savannah. Consent for Treatment I request and authorize the dentist or qualified assignee to perform the treatment that has been explained to me. Signature of Parent/Guardian: Date: 4849 Paulsen St., Suite 101, Savannah, GA Phone: (912)298-KIDS (5437) Fax: (912)

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

2460 India Hook Road, Suite 106 Rock Hill, SC 29732 E-mail: drj@rockhillkids.com Tel: (803) 327-3327 Fax: (803) 334-3474 Welcome to our practice! Please carefully complete this form so that we may better