GET ACQUAINTED QUESTIONNAIRE

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1 Aparna Aghi, D.M.D., M.S. tel fax Assistant Professor Pediatric Dentistry UCSF School of Dentistry Martin Sinai Rayman, D.D.S. Diplomate American Board of Pediatric Dentistry Dentistry for infants, children and adolescents. a pediatric dental practice built on experience - constantly progressing through innovation and enthusiasm GET ACQUAINTED QUESTIONNAIRE CHILD S Complete Name Sex Age Nickname Birthdate Home Tel. Person responsible for this account: Mother FATHER S Name Zip Code Father Other Occupation Soc. Sec.. Name of Employer Bus. Address Zip Business Telephone How long with current business MOTHER S Name Occupation Name of Employer Bus. Address Business Telephone How long with current business Do mother, father and child live together? How Long Tel. Soc. Sec.. How Long Zip Tel. If no, please explain: Names, ages of siblings Do you have a dental insurance plan? Dual? FATHER MOTHER 1. Name of employee covered under this plan 1. Name of employee covered under this plan 2. Soc. Sec.. 2. Soc. Sec.. 3. Name and Address of Insurance Co. 3. Name and Address of Insurance Co. 4. Group or Policy. 4. Group or Policy. 5. Employee s birthdate 5. Employee s birthdate I hereby authorize direct payment (of the group insurance benefits otherwise payable to me) to Aparna Aghi, D.M.D. (Signed, Insured person) I hereby authorize direct payment (of the group insurance benefits otherwise payable to me) to Aparna Aghi, D.M.D. (Signed, Insured person) Name of former dentist, if any Telephone Address of last dental care Whom may we thank for referring you to our office? Address Telephone Name of parents dentist(s) PERMISSION FOR DENTAL TREATMENT I hereby give permission to APARNA AGHI, D.M.D., M.S., and/ or MARTIN S.RAYMAN, D.D.S. to render all necessary dental services and to use such methods and agents as he or she sees fit for the child named on this form and to contact the child s physician as necessary. I understand that no treatment will be started until the recommended treatment, time involved and financial investment have been discussed with me by either Dr. Aghi, Dr.Rayman, or one of the staff members, at which time I may void this permission if I so choose. I will be responsible for any bills incurred by this child for dental treatment. Signed (Parent or Guardian) PLEASE TURN OVER TO FILL OUT OTHER SIDE

2 MeDICaL 1. Family Physician or Pediatrician (If Kaiser, include patient number): Address: HeaLtH HIStOrY This information can be of great value to better understand your child. Telephone: 2. Is your child: In good general health right now? If NO, please explain: Sensitive or allergic to any drug including penicillin or local anesthetic? At present taking any drugs? List: Allergic to food, animals, latex, dust? Other: 3. Has your child ever been hospitalized? If yes, for what? 4. Any history or difficulty with any of the following: anemia, asthma, bone disorders, brain injury, excessive bleeding, convulsions, cerebral palsy, diabetes, epilepsy, fainting or dizziness, hearing, hepatitis, heart trouble, cancer or malignancies, rheumatic fever, or premature birth or intubated? If yes please circle above and explain in more detail: 5. Are there any learning problems? 6. How would you expect your child to behave in our office? 7. Would you describe your child as (please circle) shy, frightened, apprehensive, outgoing? 8. Is there something special you d like us to know about your child and/or family? DeNtaL 1. Is this an emergency visit? 2. Is this the first visit to the dentist? 3. Has any member of your family previously been a patient of this office? Names and ages: 4. Present dental problem as you see it (if any): 5. Has your child complained about dental problems? 6. Has your child had any unhappy experiences with dental care? 7. Is your child s attitude towards dentistry good? 8. Any mouth habits: thumb sucking, pacifier, nail biting, finger sucking, grinding? 9. Has your child had any history of cavities, toothaches, pain, broken teeth, extracted teeth, gum infections, missing permanent teeth or extra permanent teeth? If yes, please circle condition(s) above. 10. Has your child ever had an injury to the head, mouth or teeth? Describe: 11. First tooth erupted at about how many months old? 12. At what age was your child weaned from the breast or bottle? 13. Name your child s favorite toy, hobby, TV show, etc. 14. School attends: 15. When and how often does your child brush? 16. Do you assist your child with brushing? 17. How often is dental floss used? 18. Is fluoride taken? If yes, circle all that apply: drops tablets vitamins toothpaste gel rinse 19. Have mother and/or father had much tooth decay? 20. Has either parent had difficulty getting numb for dental treatment? 21. Do you use tap, filtered or bottled water for cooking and/or drinking? Circle all that apply. Reviewer s Initials

3 APARNA AGHI, D.M.D. Dear Parents: Infant, Child & Adolescent Dentistry PARENT GUIDELINES You may choose whether to accompany your child to his/her filling appointment. Although we sense that some children do better without parents present, we encourage you to be with your child. If you choose to be present, we suggest the following guidelines to improve chances of a positive outcome. Please: 1. Allow us to prepare your child. 2. Be supportive of the practice s terminology. a. In words your child can understand, we will tell your child what we are going to do, show them what we will use, and do the procedure in as non-threatening and comfortable a manner as possible. b. We are selective in our use of words. Please support us by NOT using negative words that are often used for dental care. For instance, instead of: shot or needle we say metal straw or sleepy juice hurt we say pinch drill we say water whistle pull or yank tooth we say wiggle a tooth out Please avoid saying It is not going to hurt. Your child may focus on this suggestion of discomfort. 3. Be a silent observer support your child with touches like hand-holding, etc. a. This allows us to maintain communication with your child. b. Children will normally listen to their parents instead of us and may not hear our guidance. c. You may give misleading or incorrect information. 4. If asked to leave, be ready to walk away, out of your child s field of vision. You will be invited to sit back down when your child is, once again, actively helping. a. Many children will try to control the situation. b. Acting out is normal but can be unacceptable during fillings. c. We will continue to support your child at all times and you can observe (out of your child s line of vision). 5. We have an imaginary red button. If at any time, you feel uncomfortable with the situation, please let us know. Similarly, we may determine it to be advisable to stop treatment. In either case, we will discuss the situation and if necessary temporize the tooth(teeth) so that you and your child may leave, and return when we both feel it is advantageous. You can actively help in these important ways to ensure the success of your child s visit. We are confident that all will go well and hope these guidelines will prepare you with confidence for the upcoming appointment. Thank you, Dr. Aghi Dr. Rayman & Staff

4 APARNA AGHI, D.M.D. Infant, Child & Adolescent Dentistry CONSENT FOR EMERGENCY MEDICAL OR DENTAL TREATMENT California Civil Code, Section 25.8 expressly provides that a parent may authorize an adult into whose custody a child is entrusted to consent if necessary, to medical and dental treatment: Either parent, or a guardian having legal custody of a minor may give written authorization for an adult into whose care the minor has been entrusted to consent to X-ray examinations, anesthesia, medical or surgical diagnosis, and/or treatment and hospital care to be rendered to said minor under the general or special supervision and advice of a physician or surgeon licensed under the provisions of the Medical Practice Act, or to X-ray examinations, anesthesia, dental and/or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act. AUTHORIZATION In accordance with the provisions of Section 25.8 of the California Civil Code, I hereby authorize to procure medical, hospital, or dental care for my child(ren) Name(s) in the event of injury or illness while the child(ren) is(are) in the care of the above named facility or person(s). (I understand and agree that I am financially responsible for any care so provided). Signature of Parent or Guardian Physician's Name: Address: Telephone #: Medical Record #: Dentist's Name: Aparna Aghi, D.M.D., M.S. Dentistry for Children and Adolescents Address: 912 Grand Ave., Suite 202 San Rafael, CA Telephone #: (415) Fax #: (415)

5 Marin Pediatric Dentistry, Aparna Aghi, DMD Kaitlin Rodrigfuez, DDS, MS Acknowledgement of Receipt of tice of Privacy Practices Please te: It is your right to Refuse to Sign This Acknowledgement. I, [full name], have received a copy Marin Pediatric Dentistry s HIPAA tice of Privacy Practices. Print Name Signature Authority of Personal Representative to Sign for Patient (check one): Parent Guardian Power of Attorney Other: If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following: Patient s Name: For Dental Office Use Only We attempted to obtain written acknowledgement of receipt of our tice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Staff Member Signature: :