Patient Registration (Please fill out one per family)

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1 Patient Registration (Please fill out one per family) Child s First and Last Name: Date of Birth: Child s Preferred Name: Gender: Male Female Child s Address: Child s City, Zip Code: Additional Children s Names on Same Account: (2) (3) Male Female DOB: Preferred Name: Male Female DOB: Preferred Name: (4) Male Female DOB: Preferred Name: Mother s Full Name: Date of Birth: Occupation: Father s Full Name: Date of Birth: Occupation: Parents Relationship: Married Partnered Single Divorced/Separated Widowed RESPONSIBLE PARTY: (Person Financially Responsible for Account) Responsible party is (please circle): Mother Father Other Full name (if not listed above): Address (if different than above): City, State, Zip Code: CONTACT INFORMATION: Address: Home Phone: Work Phone: Cell Phone: Which number would you prefer we call for appointment confirmation: Home Work Cell Phone

2 Insurance/Family Information (Please fill out one per family) Child s Name: Today s Date: Primary Dental Insurance Information Policy holder: Mother Father Other My child does not have dental insurance Employer s Name: Insurance s Name and State: Insurance s Phone Number: ID #: Social Security number # Group #: Secondary Dental Insurance Information (if applicable) My child does not have any secondary dental insurance Policy holder: Mother Father Other Employer s Name: Insurance s Name and State: Insurance s Phone Number: ID #: Social Security Number # Group #: How did you hear about The Kids Dentist? Pediatrician Dentist Friend Advertisement Insurance Company Google Facebook Other: ***Please provide us with the name of your referral source so we may thank them: What type of water do you use? Municipal Tap Water Filtered Water (Brita, refrigerator/etc.) Bottled Water Well Water Yes No Have you had your well tested? Yes No Do you have a reverse osmosis filtration system? Is there a family history of any of the following: Missing Teeth Dental Decay Under/Over Bite Jaw Surgery Extra Teeth Gum Disease Other: Has anyone in your family had any difficulty with dental care/visits in the past? Yes No

3 Medical History (Please fill out one history per child) Child s Name: Date of Birth: Name of Child s Physician: Phone Number: Has your child ever been hospitalized or had surgery? If yes, please explain below Does your child have any medical conditions? If yes, please explain below Is your child taking any medications? If so, please list name, dosage and frequency. Does your child have any allergies to medications? Is your child allergic to anything else (i.e. gluten, dye, pets, latex, etc.)? Are your child s immunizations up to date? Comments: Does your child have any of the following conditions? Anemia Asthma Autism Birth Defects Bleeding Problems Blood Disorders Blood Transfusions Cancer Cerebral Palsy Chronic Ear Infection Cystic Fibrosis Diabetes Down Syndrome Emotional Problems Epilepsy G-Tube Feeding Hearing loss Heart Condition Heart Murmur Hepatitis Herpes High Blood Pressure HIV/AIDS Hyperactivity/ADHD Intellectual Disability Kidney Disease Learning Disability Liver Disease Muscular Dystrophy Orthopedic plates Pregnant Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures Sickle Cell Anemia Skin Disorder Sleep Apnea Snoring Speech Therapy Spina Bifida Tuberculosis Tumors X-ray treatment Other Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child s health. It is my responsibility to inform the dental office of any changes in medical status. Signature of parent/legal guardian: Date:

4 Dental History (Please fill out one history per child) Child s Name: Age: Is this your child s first dental office experience? Yes No If your child has previously seen a dentist: Name of previous Dentist: Phone Number: Date of last visit: Does the previous dentist have any X-rays? Yes No Does your child do any of the following? If your child has a history of any of these, please list the age it was discontinued. Bottle Use Currently Discontinued at age: Nursing Currently Discontinued at age: Pacifier Use Currently Discontinued at age: Thumb/Finger Sucking Currently Discontinued at age: Tongue Thrusting Currently Discontinued at age: Is your child currently experiencing any DENTAL PAIN? Yes No If so, please describe: How often are your child s teeth being brushed: Less than once a day Once a day Twice a day Three or more time a day What toothpaste is your child using? Are your child s teeth being flossed? Yes No If your child is using a mouth rinse, what rinse is it? Do you anticipate your child will be: Cooperative Uncooperative Unsure Comment: Do you have any questions you would like answered by the dentist or staff today?

5 CONSENT TO PERFORM DENTISTRY I authorize the dentists at The Kids Dentist LLC to perform upon my child (or legal ward) those procedures as may be deemed necessary or advisable to maintain my child s dental health or the dental health of any minor(s) or other individual(s) for which I have responsibility, now and in the future, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. I have been given a dental treatment plan and understand that ignoring a known dental problem has an even greater risk to my child s general health. Not treating existing dental problems in children may result in abscess, infection, pain, fever, swelling, considerable risk to the developing adult teeth, and may create future orthodontic and gum problems. I agree to the use of local anesthesia, if required, on the recommendation of the doctor. I understand and have been informed that there are possible risks and complications associated with the administration of local anesthesia. I can ask for an explanation of possible risk and benefits. I understand that as part of the dental treatment which includes preventative procedures such as cleanings and basic dentistry, and fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of the treatment. After lengthy appointments, jaw muscles may also be sore or tender. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. In some cases, sutures or additional treatment may be required. I understand that as part of dental treatment, items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and in very rare cases, require bronchoscopy or other procedures to ensure safe removal. I understand that this situation is unusual but a possible risk of treatment. I recognize that, during the course of treatment, unexpected circumstances may require additional or different procedures from those discussed. I, therefore, authorize and request the performance of any additional procedures that are deemed necessary or desirable to my child s oral health and wellbeing in the professional judgment of the dentists at The Kids Dentist LLC. I have been advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment requires that all postoperative and post-care instructions be followed, and that the regular office visits, as scheduled by my dentist, must be maintained. I acknowledge that I am responsible and I hereby agree to pay for services provided to me by The Kids Dentist LLC. I understand payment or estimated portion that insurance does not cover is due at the time of service, unless other arrangements have been made. Any unpaid balances over 90 days from time of treatment will become your financial responsibility. I have disclosed all insurance programs that my child is enrolled in on the registration forms. All cancelled appointments require 24 hour notice. Failure to contact our office to move or cancel an appointment may result in a missed appointment fee. Two missed appointments within 18 months could be cause for termination of the patient/dentist relationship. I hereby state that I have read and understand this consent, and I have been given the opportunity to ask questions. All questions about the procedure have been answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions which may arise during the course of my child s treatment. Parent Signature: Name of Parent/Guardian: Date: N. Port Washington Road Mequon, WI Phone Fax office@thekidsdentistmequon.com

6 Acknowledgement of Receipt of HIPAA Notice of Privacy Practices I hereby acknowledge that I have received and reviewed a copy of The Kids Dentist LLC s HIPAA Notice of Privacy Practices. I understand that The Kids Dentist LLC s HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of The Kids Dentist s revised HIPAA Notice of Privacy Practices upon request. I understand that, if I have questions about The Kids Dentist LLC s HIPAA Notice of Privacy Practices, I may contact Shane Fisher at I understand that it is my right to refuse to sign this Acknowledgement should I so choose and that The Kids Dentist LLC will not refuse treatment to me if I refuse to sign this Acknowledgement. I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding The Kids Dentist LLC s privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Shane Fisher, noted above, for assistance. Parent/Legal Guardian Signature: Date: FOR OFFICE USE ONLY Staff Initials: The Kids Dentist LLC made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, The Kids Dentist LLC was unable to obtain a signed Acknowledgement for the following reason(s): Refusal to sign Acknowledgement on, 20. Communications barriers prohibited us from obtaining a signed Acknowledgement. An emergency situation prohibited us from obtaining a signed Acknowledgement. Other (Describe): N. Port Washington Road Mequon, WI office@thekidsdentistmequon.com Phone Fax

7 Financial Agreement Payment is expected in full for each appointment as services are rendered. Payment options are: Cash Check Credit Card (MasterCard, Visa, American Express, Discover, CareCredit) If we are in-network with your insurance, only the anticipated copay will be required at time of service. Additional charges may apply once your insurance has settled the claim. Dental Insurance: Your insurance benefits are determined by the type and design of the plan chosen by you and/or your employer and we are not a party to this contract. We have no control over the terms of your contract, the method of reimbursement, frequency of services allowed or the determination of your benefits. Some or all of the services provided can be defined by your insurance company as not covered, denied, over UCR, or out of network. We will file your primary dental insurance claims as a courtesy to you. We do not guarantee payment and we are not responsible for providing you plan limitation, exclusion and provisions determined by your insurance company. You agree to be responsible for payment of all services rendered on behalf of yourself or your dependents. Your estimated out of pocket responsibility for treatment rendered is due in full at the time of service. A billing charge may apply for any balance not paid in full. If your insurance requires a referral, you are responsible for obtaining it. We will file a pre-determination for recommended treatment when it is requested by you. A predetermination could cause a delay in treatment up to 4-6 weeks based on your insurance. All predeterminations or treatment plans for recommended treatment are only estimates. By signing this document, you authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered of my child during the period of such dental care to third party payers and/or other health practitioners. Missed Appointment Fee: A missed appointment is failing to show up for an appointment or changing/cancelling an appointment with less than 24 hours notice. We ask that if you change an appointment to provide us with at least 24 hours notice. There is a $25 fee for the first missed appointment, and a $50 fee for the 2 nd missed appointment. After the 2 nd missed appointment within 18 months, you may be asked to transfer your records to another dental practice. Past Due Accounts: We will send monthly statements to the address on file for the responsible party on the account. A maximum of 3 statements will be sent regarding any account balance. Any account that has an unpaid balance over 30 days will have a finance charge (15%) added monthly to the account as well as a $25 late fee. Any account that has a past due balance of 90 days or more or any account that has a financial contract in default will have additional steps taken to collect those debts. If we have to refer your account to a collection agency, you agree to pay 33.3% attorney fees and all court costs incurred. Any returned check will be subject to a $35 bank charge as well as late fees, if applicable. Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. RESPONSIBLE PARTY (PRINTED): RESONSIBLE PARTY (SIGNATURE): DATE: N Port Washington Rd Mequon, WI office@thekidsdentistmequon.com phone (262)

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