Child Health and Dental History Form

Transcription

1 3205 SE 192 nd Ave Suite 100, Vancuver WA Office Fax Child Health and Dental Histry Frm Child s Name: DOB Address: Phne# Gender: Male Female 1 st Parent Infrmatin Mther Father Guardian Fster Stepparent Name: DOB Phne# Secndary Phne# /Text Appintment Cnfirmatins? YES NO 2 nd Parent Infrmatin Mther Father Guardian Fster Stepparent Name: DOB Phne# Secndary Phne# /Text Appintment Cnfirmatins? YES NO Hw did yu hear abut us? Please write name belw Family Friend Dctr Advertisement Other Pediatrician Name: Phne# Specialist Name: Phne#

2 Health Histry Please Check if yu child has had a histry f, r currently has any cnditin related t any f the health cnditins belw: Accidents r Severe Infectins Ear aches/infectins Speech Issues Allergies (Seasnal) Enlarged Tnsils Skin Issues Anemia r Bld Disrders Headaches STD Arthritis Heart Murmur Thyrid/Endcrine Asthma r Lung Prblems Hepatitis/Liver Issues Autism r Autistic Spectrum Disrders Tbacc/Drug use Bladder r Kidney Prblems HIV+/AIDS Tuberculsis Bne Disrders ADHD/ADD Visin Disrders Bleeding Prblems Latex Allergy Other Bld Transfusin Measles Cancer (Malignancies) Mumps Cerebral Palsy Pregnancy (Teen) Cnvulsins, Seizures r Rheumatic Fever Epilepsy Sickle Cell Develpmental Disabilities Snring Diabetes Please List any fd allergies: Please List any current medicatins: Des yur child have any allergies t medicatins? YES NO If yes please list:

3 Medical Histry YES NO 1.) Has yur child ever been hspitalized r had any type f surgery? If yes, please explain: YES NO 2.) Has yur child ever had any type f sedatin r general anesthesia? If yes, please explain: Any cmplicatins? YES NO 3.) Des yur child have any develpmental, mental, r physical- Impairment? If yes, Please explain YES NO 4.) Has yu child had any excessive bleeding when cut r injured? YES NO 5.) Des yur child require antibitics fr dental treatment due t a heart cnditin, prsthetics, shunt, rgan transplant, r ther medical reasn? If yes, please explain: YES NO 6.) Des yur child have any genetic r inherited disrders? If yes, please explain: YES NO 7.) Is yur child being treated fr any ther illnesses nt mentined n This frm? If yes, please explain: Dental Histry YES NO 1.) Is this yur child first dental visit? If nt, when was the last time? YES NO 2.) Has yur child ever had an unpleasant experience at a previus Dentist? If yes, Please explain YES NO 3.) Has yur child every injured their muth, teeth, r head? If yes, please explain YES NO 4.) What type f water des yu child drink mst frequently? City Bttled Filtered Well YES NO 5.) Des yur child take fluride supplements? If yes, please explain YES NO 6.) Des yur child use flurinated tthpaste? YES NO 7.) D yu brush yur child teeth? Hw many times per day? When? YES NO 8.) D yu supervise r assist yur child with brushing? YES NO 9.) Des yur child snack frequently between meals? YES NO 10.) Hw much juice des yur child drink daily? Nne 4-6 z (ne cup) 6-12 z (tw cups) Mre than 12 z YES NO YES NO YES NO 11.) Des yu child participate in any sprts r ther activities? If yes, please explain 12.) Has yur child cmplained f any dental-related pain recently? If yes, please explain 13.) D yu have any ther dental cncerns r cmments yu wish Addressed? If yes, please explain

4 Habit Histry Please let us knw abut past and current feeding and childhd habits Breast Feeding Past Current Nt Applicable Age When Stpped Baby Bttle Use Cntents: Sippy Cup Use Cntents: Thumb/Finger Sucking Pacifier Teeth Grinding/Clenchin g Authrizatin: I certify and I have read and understand the abve infrmatin t the best f my knwledge. The abve questins have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my child s health. It is als my respnsibility t infrm this ffice f any changes in my child s medial status. Printed Name Signature f Parent r Guardian Date

5 Dental Insurance Infrmatin Primary : Insurance Cmpany Name: Grup# ID/SSN# Billing Address: Phne# Plicy Hlders Name: DOB Relatinship t Child: Emplyer: Secndary (if applicable): Insurance Cmpany Name: Grup# ID/SSN# Billing Address: Phne# Plicy Hlders Name: DOB Relatinship t Child: Emplyer: I certify that, as this child s parent/legal guardian, all f the infrmatin I have prvided in this frm has been cmpleted t the best f my knwledge. I understand that my dental insurance carrier may pay less than the billable amunt fr services rendered. I agree t be respnsible fr all r any payment f all services rendered n behalf f my dependents. Insurance fraud hurts yu and yur children, and can subject yu t criminal and civil penalties. Due t the serius nature f this ffense and because this cnduct may increase the expsure and expenses incurred by this ffice, we must enfrce this plicy. Please ensure yu have ntified ur frnt desk f all private and state insurance plans yur children is enrlled in. If insurance fraud is discvered after signing this frm, Under the Sea Dentistry is entitled t: Administrative fee f $50.00 Payment fr any mnetary difference between signed treatment plan and changes that result frm new insurance infrmatin Refuse services and deactivate patients frm the clinic Reprt f fraud t the prper authrities Failure t disclse insurance infrmatin is a crime under Washingtn state law and is a class C Felny and can require jail time and fines. I, the legal guardian and r parent f the minr listed and have read and understand the insurance cverage frm. Further, I have disclsed any and all frms f private and r state funded insurance available fr my child(ren). Parent/Legal Guardian Signature Date

6 I the parent/legal guardian is giving permissin fr thse listed belw t bring my child/children t their appintments, make decisins fr dental treatment and make future dental appintments. This is als authrizing, Under the Sea Dentistry fr Children s staff t share any infrmatin they feel necessary t help aid in the treatment prcess fr my child/children with thse listed belw. Name: Phne: Relatinship: Name: Phne: Relatinship: Name: Phne: Relatinship: Parent Signature: _ Date: 3205 SE 192 nd Ave Suit 100 Vancuver, Washingtn Office Fax

7 Office Plicies Patient : At Under the Sea Dentistry, custmer service is ur tp pririty. It helps us t make sure that we are ding the very best fr yu and yur family. In an effrt t create an envirnment that allws us t be ur very best, we have established ffice plicies that we wuld like yu t review. If yu have any questins, please d nt hesitate t ask us. Late Arrivals: We ask that yu arrive at least 15 minutes prir t yur appintment time in rder t answer any questins yu may have, take care f any insurance r payment issues that may arise, and allw adequate time t care fr yur child. We always strive t minimize wait times fr all patients. Therefre, in rder t avid cmprmising yur child s care, and in fairness t ther patients wh have arrived n time, late patients may be reschedule if there is insufficient time t care fr yu child. We will try t accmmdate late arrivals as time permits, but thse patients wh are n time will be seen first. N Shw Plicy/Late Cancellatins: We exclusively reserve time t care fr yur child, and we expect patients t be present at their appintment time. T avid a charge f $25.00 fr missed r late cancelled appintments, we request 48-hur ntice. This fee must be paid befre scheduling anther appintment. We understand last minute issues may arise, and ffer leniency in sme cases, but repeatedly missed r cancelled appintments unfairly use time that may be ffered t anther child wh requires dental treatment. Phts/Vides: We understand that a child s first dental visit is an imprtant milestne in yur child s life. We ask that yu infrm us first, s that we may ensure that ur staff des nt appear in any recrdings r pictures with ut their cnsent. Als, we ask that yu refrain frm recrding r taking pictures nce prcedures have started and during curse f treatment. Financing: We are cmmitted t prviding high-quality, affrdable dental care fr yur child, we ffer a variety f payment ptins. Patients Withut Dental Insurance : Fr patients withut dental insurance, payment is due the same day services are rendered, regardless f wh accmpanies the child t his r her appintment. Fr yur cnvenience, we ffer a 10% discunt fr thse wh pay with cash, checks, and all majr credit cards. We als ffer lw/n interest financing thrugh Care Credit but due t the fees we are nt able t ffer a 10% discunt.

8 In-Netwrk Insurance Patients: We are preferred prvider fr many majr insurance dental plans. If we are an in-netwrk prvider fr yu plicy, we will file yur claim as a curtesy and will accept estimates f benefit payments frm these insurance cmpanies. Yur prtin f c-payment and r/c-insurance is due at the time f service. Please keep in mind that this is nly an estimate f what yur insurance will cver fr yu. If there is any difference after yur insurance pays, we will cntact yu t make the necessary prper adjustments. Out-f Netwrk Insurance Patients: If we are ut f netwrk fr yur insurance, please check fr any ut f netwrk benefits and we will file yur claim fr yu as a curtesy. Althugh we can smetimes estimate what yur insurance cmpany will pay, there is n guarantee f reimbursement. Any remaining balance will be yur respnsibility. It is imprtant t understand that yur insurance is a cntract between yu, yur emplyer, and the insurance cmpany, nt ur ffice. N matter what yur insurance status may be, please keep in mind that, ultimately yu are respnsible fr timely payment n yur accunt. If yur insurance cmpany has nt paid yur claim in full within 30 days, yu will be ntified s that yu can discuss the matter with yur insurance cmpany. If the claim is nt paid within 45days, the balance and all fllw-up with the insurance cmpany becmes yur respnsibility and all remaining balances will be due with in 30 days. Please call ur ffice at (360) fr mre infrmatin, and let us knw if yu have any questins r cncerns regarding ur ffice plicies. We value the trust that yu have placed in us fr yur child s dental care. Welcme t the Under the Sea Dentistry Family. I have read, understand and agree t abide by Under the Sea Dentistry ffice plicies: Print Name: Signature: Relatinship t child:

9 Financial Agreement Please Read Carefully Patient Name: If yu d nt have insurance t bill then payment is required same day the services are rendered. Initial Dental insurance is an agreement between yu and yur insurance cmpany. We can nly estimate yur dental benefits. This estimate is nt a guarantee f payment by yur insurance cmpany. Yu are respnsible fr any charges yur insurance cmpany des nt pay. Yur Estimated ut f pcket prtin, (c-pays) and deductibles are due at time f service. There is a $35.00 charge fr any returned checks and then a check will n lnger be accepted. A billing charge will be applied t any accunt which has a balance 60 days past due. This mnthly fee is a minimum f $ There is a $ charge fr all accunts that are sent t cllectins. Printed Name: Date Signature Relatinship t child