Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION

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Home Address: Home Telephone: CHILD 1 First Name: Last Name: School: Age: Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION PATIENT INFORMATION Birthday: / / Sex: M F CHILD 2 First Name: Last Name: School: Age: Birthday: / / Sex: M F CHILD 3 First Name: Last Name: School: Age: Birthdate: / / Sex: M F PARENT INFORMATION PARENT 1 PARENT 2 Martial Status: Single Married Divorced Widowed Martial Status: Single Married Divorced Widowed Name: Name: Birth date: / / Birth date: / / Address (if different): Address (if different): Occupation: Employer: Business Phone: Cell Phone: Email: Occupation: Employer: Business Phone: Cell Phone: Email: May we email or text you to confirm your child's appointment? YES NO INSURANCE INFORMATION Primary Coverage Secondary Coverage (if applicable) Insurance Carrier: Insurance Carrier: Subscriber Name: Subscriber Name: Social Security: Social Security: Name of person responsible for account: **Please present your DENTAL insurance card on your initial visit & if you have changed insurance coverage recently** REFERRAL HISTORY Whom may we thank for referring you? Family Internet: Friend: School visit by doctor @ Ins. Plan Dr.: Other: I authorize Dr. Rumack to perform the necessary dental service my child may need for his/her well-being. I also authorize Dr. Rumack to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or health practitioners. I request that my insurance company pay directly to Dr. Rumack, and I understand that my insurance carrier may pay less than the actual bill for service; therefore, I agree to be responsible for payment of all services rendered on my child's behalf. I authorize the use of this signature on all my insurance submissions. Parent/Legal Guardian (PRINT): Parent/Legal Guardian (Signature): Date: 1

Patient Name: Birthdate: / / Age: Sex: M F Patient Physician: Phone: Is/Has your child: Y N Immunizations current? If no, please explain: Any illnesses now? Type: Taking any medications? List: Ever been hospitalized? Ever had surgery? My Child is allergic to: MEDICATIONS: LATEX: OTHER ALLERGIES: Y Calabasas Pediatric Dentistry & Orthodontics MEDICAL HISTORY List List: Has/Had any history of: Y N Y N Y N ADD/ADHD Down Syndrome HIV/AIDS Anemia Developmental Delay Kidney Disease Asthma Diabetes Liver Disease Autism Eye Problems Mental Disturbances Bleeding Disorder Fainting/Dizziness Muscular Dystrophy Blood Transfusion Frequent Ear Infections Orthopedic Problems Brain Injury Hearing/Speech Problems Rheumatic Fever Bruising Easily Heart Murmur Sleep Apnea Cerebral Palsy Heart Problems Tonsil Problems Chronic Headaches Hepatitis Tuberculosis Convulsions/Seizures Hyperactivity Tumors/Cancer Special Needs/Other: DENTAL HISTORY Reason for this appointment: Please specify any dental and/or orthodontic concerns: Name of previous dentist: Last dental visit date: / / Last X- rays were taken on: / / Has Child had experience with: Y N Y N Y N Dental pain in the past? Adverse reactions to: > Nail biting Fillings or extractions? > Dental anesthetics? > Grinding teeth Sealants applied? > Any dental materials? > Lip sucking/ biting Fluoride supplements? Dental Habits: > Mouth breathing Dental injuries? > Thumb sucking > Sleeping with a bottle Dental sedation? > Pacifier usage > Tongue thrust Has your child ever had an unhappy dental experience, please explain: How would you describe your child's previous dental experience? Excellent Good Fair Poor N 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 my child's medical status. Parent/Legal Guardian (PRINT): Parent/Legal Guardian (SIGNATURE): Date: 2

OFFICE POLICIES FOR PEDIATRIC DENTISTRY AND ORTHODONTICS Welcome to our Practice! We are delighted that you have chosen our office to care for your children s dental needs. Our primary goal is that your children receive the optimal care needed to restore and maintain their oral health. It is the intention of the following office polices to assist in making your treatment as pleasant and efficient as possible. Please help us help you! Thank you! Payment Charges: All new and current patients will be required to pay the estimated patient portion for dental treatment the day that services are rendered. We accept cash, personal checks, and for your convenience MasterCard, American Express, Visa and Discover. Your time is valuable as well as the doctor s. That is why we strive to take patients on a timely matter. If you are unable to keep your appointment, please give us a 24-48 hour notice. Failure to do so will result in a $65 dollar cancellation fee. Any late appointments may have to be rescheduled, and a broken appointment fee of $65 may be applied for re-occurring offenses. Insurance: Our office is committed to helping you maximize your insurance benefits. We will do our best to assist you in billing your insurance company. Please understand that your insurance policy is a contract between you and your insurance company. IT IS YOUR RESPONSIBILITY TO KNOW IF OUR OFFICE IS PARTICIPATING OR NON-PARTICIPATING WITH YOUR INSURANCE PLAN. AS OF APRIL 20, 2017 THIS OFFICE IS ONLY IN- NETWORK WITH DELTA DENTAL PREMIER, BLUE SHIELD OF CA, AND CIGNA PLEASE KEEP IN MIND THAT OUR CONTRACT WITH ANY OF THE LISTED INSURANCES MAY BE DROPPED AT ANY TIME. BECAUSE INSURANCE PLANS VARY, WE CAN ONLY ESTIMATE YOUR COVERAGE IN GOOD FAITH, BUT CANNOT GUARANTEE COVERAGE DUE TO THE COMPLEXITIES OF INSURANCE CONTRACTS. Your estimated patient portion, along with unpaid deductibles, must be paid at the time of service. As a service to our patients, we will bill insurance companies and allow them 45 days to render payment. After 60 days, you are responsible for the entire balance, paid-in-full. If you have any questions, please call our office and we will be happy to assist you. Overdue accounts: Balances older than 90 days may be subject to additional collection fees and finance charges if such actions become necessary. Returned checks will have an additional fee of $35.00 added to the amount of the returned check. We encourage you to communicate any such problems to us so that we can assist you in the management of your account. However, our office will bill you directly for any outstanding balances. It is your responsibility to keep your mailing address and phone numbers updated to help keep your account current. Parents: Our office asks that a parent or guardian be present during the dental visit. Again, thank you for choosing Calabasas Pediatric Dentistry & Orthodontics to care for your children. We do not take for granted the precious children you entrust us with. We appreciate the opportunity to care for them! By signing below, I acknowledge that I am the parent or legal guardian of. I have read and understood the office polices and agree to adhere them. I also understand that my signature below serves as an assignment for the purposes of any insurance reimbursement in which case, I understand it may be sent to the office. Signature Relationship Date 3

CALABASAS PEDIATRIC DENTISRTY & ORTHODONTICS ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE *** You May Refuse to Sign This Acknowledgement*** I,, have received a copy of this office s Notice of Privacy Practice Please Print Name Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: Individual refused to sign Communications barriers interfered with obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment Other (Please Specify) 4

Release of Records I authorize the office of Dr. Elena Rumack and Dr.Lecia Harmer to receive a copy of my child's/children's complete dental records, including any x-rays, to be sent to:smiles@calabasastoothfairy.com Please attach this form with requested information to the email. Thank you! Child #1 Name: Date of Birth: Child #2 Name: Date of Birth: Child #3 Name: Date of Birth: Child s Previous Dentist/Office: Parent/Legal Guardian Name: Signature: Date: 5

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