Parent/Guardian Registration Form

Parent/Legal Guardian's Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Preferred Name

Gender

Date of Birth

Your Relationship to Patient

Mother

Father

Legal Guardian

Foster Parent

Other

Parent/Legal Guardian's Information [#1]

First Name

Last Name

Middle Initial

Preferred Name

Title (Mr/Ms/Mrs/etc)

Marital Status

Married

Single

Separated

Divorced

Widowed

Date of Birth

Home Phone

Cell Phone

Work Phone

Best Time to Call

Preferred Method of Contact

Phone

Text

Occupation

Social Security #

Mailing Address

City

State

Zip

How did you find out about our office?

Physician

Dentist

Friend

Insurance

Internet

Other

Whom may we thank for referring you?

Parent/Legal Guardian's Information [#2]

First Name

Last Name

Middle Initial

Preferred Name

Title (Mr/Ms/Mrs/etc)

Marital Status

Married

Single

Separated

Divorced

Widowed

Date of Birth

Home Phone

Cell Phone

Work Phone

Best Time to Call

Preferred Method of Contact

Phone

Text

Occupation

Social Security #

Mailing Address

City

State

Zip

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care, to third party payers or health practitioners. I authorize and request my insurance company to pay benefits directly to the said dentist(s). I understand that my insurance company may pay less than expected. I agree to be responsible for all of the services rendered for my child(ren). I understand that any appointment failures with less than 24 hours notice may incur a cancellation charge. I am aware that a service charge of 1.5% per month (18% per annum) on unpaid balances will be charged on all accounts. In addition, I agree to pay all legal fees and/or collection costs incurred in collecting delinquent accounts.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Health History Form

Parent/Legal Guardian's Email Address

Today's Date

Patient Information

First Name

Last Name

Middle Initial

Preferred Name

Gender

Date of Birth

Previous Visit

Contact Information

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Parent/Legal Guardian's Name(s)

Pediatrician's Name

Pediatrician's Phone Number

Health History

Does your child have any medical conditions or disabilities?

Yes

If yes, please list

Have you ever been told your child needs antibiotics before a dental visit?

Yes

Has your child ever had heart or cardiac problems?

Yes

Has your child had any surgeries or hospital visits?

Yes

If yes, please list

Does your child take any medications on a daily basis?

Yes

If yes, please list

Does your child have any food or medication allergies?

Yes

If yes, please list

Is your child allergic to latex, pine nuts, or dairy products?

Yes

If yes, please list

Does your child have asthma or reactive airway disease?

Yes

What asthma medications were used last and when?

Please select all the conditions your child currently has, or HAS HAD in the past.

Heart Murmur

Cleft Lip/Palate

Tuberculosis

Hepatitis

Seizures

Hearing/Visually Impaired

Rheumatic Fever

Diabetes

Developmental Delay/CP

Eczema

HIV/AIDS

Ports/Catheters

Anemia/Sickle Cell

Ear Problems

Autism/PDD

Liver/Kidney Disorders

ADD/ADHD

Cancer

None

Does your child have any physical or mental disabilities or speech problems?

Yes

If yes, please explain

Dental History

What is the reason for your visit?

Is this your child's first visit to the dentist?

Yes

How do you think your child will do at this visit?

Good

Apprehensive

Uncooperative

Has your child ever had a negative dental experience in the past?

Yes

Has your child had a toothache recently?

Yes

If yes, please explain

Does your child have any of the following habits?

Finger Sucking

Pacifier

Teeth Grinding

None

What type of water does your child drink?

Tap

Fridge

Bottle

Brita

Pur

Other

Has your child ever had any injuries to the jaw, head, mouth, or teeth?

Yes

If yes, please explain

Is there anything else about your child that you think we should know in order to better treat their dental needs?

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I acknowledge that the above information is correct and grant permission to provide my child’s dental and related medical/surgical treatment as deemed necessary, utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete their treatment.

If there is a change in my child’s health, allergy or medication history, I will inform the dentist & staff immediately prior to any future appointments.

Name of Parent/Legal Guardian

Signature of Parent/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Insurance Form

General Information

Patient Name

Date of Birth

Primary Dental Insurance

Policy Holder

Self

Other

Policy Holder Name (if not patient)

Relationship to Patient

Self

Spouse

Parent

Legal Guardian

Partner

Other

If other, please specify

Name of Employer

Work Phone

Address of Employer

City

State

Zip

Policy Holder Date of Birth

Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

Secondary Dental Insurance

Policy Holder

Self

Other

Policy Holder Name (if not patient)

Relationship to Patient

Self

Spouse

Parent

Legal Guardian

Partner

Other

If other, please specify

Name of Employer

Work Phone

Address of Employer

City

State

Zip

Policy Holder Date of Birth

Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

If I am entitled to benefits under any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan. I understand that it is my responsibility to know if this office is in/out of network and what my coverage consists of.

Initial

I give my consent for examination and treatment.

Initial

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to

Spouse

Family

Friend

Other Treating Physician(s)

Do Not Release my Medical Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Patient Screening Form

General Information

Patient Name

Today's Date

Patient Screening

Have you/they recently been vaccinated for COVID-19?

Yes

Have you/they recently received a booster shot for COVID-19?

Yes

If yes, when was your/their last shot?

Which vaccination did you/they receive?

Have you/they recently been tested for COVID-19?

Yes

If yes, please specify test date.

Have you/they tested positive for COVID-19?

Yes

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes

Are you/they having shortness of breath or other difficulties breathing?

Yes

Do you have a cough?

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

Have you/they experienced recent loss of taste or smell?

Yes

Are you/they in contact with any confirmed COVID-19 positive patients?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Is your/their age over 60?

Yes

Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Yes

Have you/they traveled in the past 14 days to any regions affected by COVID-19?

(as relevant to your location)

Yes

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue