Tell Us About Your Child
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- Morgan Barton
- 5 years ago
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1 5C Medical Park Drive Pomona, NY (845) Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and your family and look forward to working with you to maintain your child s oral health. Please fill out this form as completely as possible. If you have any questions, we will be happy to help. Tell Us About Your Child Child s Name q M q F Last First MI Nickname Child s Birthdate / / Age Address City State Zip Does Your Child Play Sports? q Yes q No If Yes, What Sports How did you hear about our Office? (please list name) q Pediatrician/Other Dentist q Friend q School/Church/Synagogue q Google q Yelp q Local Newspaper q NY Metro Parents Magazine q NY Metro Parents Website q Other Mother s Information Name DOB / / Occupation SS# - - Employer (name/address) Cell Phone Home Phone Work Phone Preferred Method of Contact: q Text Message q q Cell Phone q Work Phone q Home Phone
2 Father s Information Name DOB / / Occupation SS# - - Employer (name/address) Cell Phone Home Phone Work Phone Preferred Method of Contact: q Text Message q q Cell Phone q Work Phone q Home Phone Who is accompanying the child today? Name Relationship Authorized Nanny/Sitter/Au Pair In the event that I am unable to bring my child in for an appointment the following individuals have my permission to accompany my child and make any necessary decisions for my child s care. This includes consenting to any necessary treatment plan changes. Name Relationship Contact Number The legal guardian must accompany their child/children for the first appointment. Insurance/Financial Information Name of Dental Insurance Company Telephone # of Insurance Company Policy Holder ID # Group # *First time patients, please bring your dental insurance card to the office or copies of both sides in advance of the first appointment. Policy Owner s Name Relationship to Patient Policy Owner s Birthdate Social Security # Policy Owner s Employer
3 Health History Your Child s health is q Excellent q Fair q Poor Child s Physician Phone # Date of last physical exam / / Has your child ever been hospitalized overnight? q Yes q No When? Reason for hospitalization Vaccinations up to date? q Yes q No History of Surgery? q Yes q No Type of Surgery Does your child have any allergies to food? q Yes q No If yes, please list Does your child have any allergies to medicine? q Yes q No If yes, please list Has your child ever had any of the following conditions? q Asthma q Autism Spectrum Disorder q ADHD q Heart Murmur q Congenital Heart Defect q Arrhythmia q Epilepsy/Seizures q Artificial Heart Valve q Cancer/Tumors q Leukemia q Lymphoma q Sickle Cell q Artificial bones/joints q Recurrent Ear Infections q Cleft Lip/Palate q Developmental Delay q Birth Defects q Glaucoma q Thyroid Function Issue q Cerebral Palsy q HIV/AIDS q Blood Transfusion q Abnormal Bleeding q Hemophilia q Endocrine Function q Issue Fainting/Dizziness q Lung Disease q Crohn s Disease q High/Low Blood Pressure q Hearing Loss q Ulcerative Colitis q Liver/ Hepatitis q G6PD q Gluten/Celiac Disease q Diabetes q Anemia q Kidney Disease q Jaundice q Tuberculosis q Other not listed Please List ALL medications your child takes, their dosages and frequency
4 Dental History Reason for Today s Visit Is this your child s first visit to the dentist? q Yes q No If not, who was the previous dentist Phone # When was your child s last exam? / / When were x-rays taken? / / If x-rays were taken, please ask previous office to records to drsmith@smithslittlesmiles.com Has your child had any previous dental injury? q Yes q No If yes, when? / / Does your child require pre-medication prior to dental treatment? q Yes q No Has your child had a history of the following and if so when did they stop: q Bedtime Bottle q Fluoride Vitamins q Pacifier q Breast Feeding q Iron Supplements q Teeth Grinding q Bottled Water q Mouth Breathing q Snoring q Thumb Sucking q Finger Sucking q Fingernail Biting q Sleep Apnea q TMJ q Other Habits Age Stopped What Kind of multivitamin does your child use, if any? q Chewable q Liquid q Drops q Gummy q None Does your child take a fluoride supplement prescribed by a pediatrician or a previous dentist? q Yes q No Do you brush your child s teeth or do they brush independently? Does your child use: q Floss/Flossers q Fluoride Rinse (ie ACT) Has your child had any previous negative dental experiences? q Yes q No If yes, please explain Please list any additional questions or concerns you may have
5 HIPAA Privacy Practices Notification I, the undersigned parent/legal guardian of, have been issued the HIPAA Notice of Privacy Practices. I fully understand that the Practice is required by law to maintain the privacy of my child's medical and health information. I acknowledge that the Practice will use and disclose my child's health information for the purposes of treating my child, obtaining payment for services rendered to my child and conducting health care operations. Authorization and Release To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk. Furthermore, I understand that it is my responsibility to inform this dental office of any changes in my child s medical status. I authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such dental care to third party payors and/or other health practitioners as necessary. I hereby authorize the Dr. Marita Smith or any other doctor employed by Smith s Little Smiles to perform the examination and after explanation, any and all treatment for the above named child including radiographs if indicated and consent to such methods, drugs and agents that may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that, as a condition of my child's treatment by this office, financial arrangements must be made in advance. Parent/Guardian s Signature Parent/Guardian Name Printed Date
Tell Us About Your Child
GIVNG TREE PEDIATRIC DENTISTRY Rebekah Tannen DDS 110 Washington Avenue Pleasantville, NY 10570 Tel: 914-579-2225 Fax: 914-579-2226 Email: Team@givingtreedental.com www.givingtreedental.com We are thrilled
Address (if different from above):
Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
Chapel Hill Pediatric Dentistry
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Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
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Chapel Hill Pediatric Dentistry
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Child Health/Dental History Form
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New Patient Information
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Child s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:
Welcome Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their
Welcome to Skyline Pediatric Dentistry!
Welcome to Skyline Pediatric Dentistry! Patient Information Patient Name: Preferred Name: Today s Date: Birth Date: Age: Social Security #: Male Female Names of siblings: Responsible Party Information
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
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Patient s Full Name Age Sex: (M) (F) Whom may we thank for referring you?
Date: / / Patient Information Patient s Full Name Age Sex: (M) (F) Nickname (if any) Birthdate: / / Whom may we thank for referring you? General Information Parent/Legal Guardian (full name) Birthdate:
----PATIENT INFORMATION---- Patient s Full Name Preferred Name DOB Age Sex. School Grade. Residence Address. City State Zip Home Phone #
Buckhead Pediatric Dentistry, LLC Pediatric and Adolescent Dentistry 3280 Howell Mill Road, NW Suite 230 Atlanta, GA 30327 404.351.PEDO (7336) general@buckheadpediatricdentistry.com ----PATIENT INFORMATION----
How did you hear about us? Dentist Family Friend Pediatrician Community Event Website. Internet Yellow Pages Val Pak Other
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PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance
1 Today s Date: 2 (225) 664-2646 (225) 664-2640 (fax) 245 VETERANS BLVD. DENHAM SPRINGS, LA 70726 Who is Accompanying Your Child Today? Name: Relation: Do you have legal custody of this child? Yes No Tell
PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
Get Acquainted Questionnaire Tell Us About Your Child!
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Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
Patient Registration Patient s Full Name: Home Address: Home Phone Number: Cell Phone Number: Social Security #: DOB: Relationship Status: Married Divorced Single Place of Employment: Work Address: Work
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
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NEW PATIENT PAPERWORK
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We are delighted and honored that you have chosen us to provide your child with the best dental care possible. We to treat children in our practice!
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Who is responsible for this account Relationship to patient. How did you hear about us (referral, facebook, etc.)?
EMERGENCY CONTACT INSURANCE PATIENT INFORMATION Name of Minor/Child SSN Sex: M F Age Birthdate Nickname Mailing Address City, State, Zip Physical Address City, State, Zip Home Phone Work Cell Email Address
Patient Registration (Please fill out one per family)
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Names and ages of other children in family School Grade. Employer Phone
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Patient Registration
Patient Registration Last Name First Name Middle Initial Street Address Apt/Unit City, State Zip Home Phone Cell Phone (Text ok? ) Email Address Primary Number to call first: Birth Date / / Age Sex Marital
COLVIN AVENUE DENTAL. Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York WELCOME LETTER. Dear
WELCOME LETTER Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York 12206 518-459-7993 Dear Welcome to our dental practice. Our dedicated and experienced team has been providing quality and comfortable
Acknowledgement of receipt of notice of privacy practices
Acknowledgement of receipt of notice of privacy practices NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a Notice of Privacy Practices from Kettering Physician Network (dba Kettering Cancer
Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
Jennifer Unger Waters, D.D.S., P.C. 1607 Washington Avenue Golden, CO 80401 (303)279-6621 WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely
Emergency Contact Information: Name Address Phone Number. How did you hear about our office? Reason for your visit today?
Welcome to Our Office! Patient Registration Paul S. Jackson, D.M.D. 1345 E. Fort Union Blvd. Salt Lake City, Utah, 84121 Patient s Name Birth Date Age Gender Home Address City State Zip Home Phone Cell
DENTAL INSURANCE PRIMARY COVERAGE DENTAL INSURANCE SECONDARY COVERAGE
SO THAT WE MAY PROCESS YOUR ACCOUNT AND/OR INSURANCE CORRECTLY, PLEASE COMPLETE THIS PATIENT ACCOUNT REGISTRATION FORM. _ WHO IS RESPONSIBLE FOR THIS ACCOUNT?_Circle one:_mr MRS MS MISS DR NAME: ADDRESS:
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Responsible Party Address City State Sex M F Age Birthdate Married Widowed Single Minor Separated
Patient Registration To help us meet all of your child s dental needs please fill out this form completely and accurately. PATIENT INFORMATION
Patient Registration To help us meet all of your child s dental needs please fill out this form completely and accurately. PATIENT INFORMATION Name: Birthdate: Age: Male/Female Address: City: State: Zip:
Date: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/