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: / / Relationship to Child SSN: - - Home Address Home Phone Cell Phone Email Employer Job Title Work Address Work Phone Is it okay to contact this parent via: Home Work Cell Email Parent/Legal Guardian (full name) Birthdate: / / Relationship to Child SSN: - - Home Address Home Phone Cell Phone Email Employer Job Title Work Address Work Phone Is it okay to contact this parent via: Home Work Cell Email Parent(s) are: Married Divorced Single Widowed Partners Child Lives with: Who is responsible for the account?
Social History What is your child most interested in? Names/Ages of Brother(s)/Sister(s) Is your child adopted? (Y) (N) Name of Child s School What is the primary reason for today s visit? Health History Child s Pediatrician Phone # Has your child ever had any of the following? ADHD/ADD (Y) (N) Eating Disorder (Y) (N) Allergies (if Yes, see below) (Y) (N) Eczema/Skin Problems (Y) (N) Anemia (Y) (N) Emotional/Psychological Difficulties (Y) (N) Asthma/Respiratory System/Pneumonia (Y) (N) Epilepsy/Seizures (Y) (N) Autism (Y) (N) Fainting/Dizziness (Y) (N) Bladder Problems (Y) (N) Glaucoma/Eye Problems (Y) (N) High/Low Blood Pressure (Y) (N) Hearing Impairment (Y) (N) Bone Disorder/Joint Problems (Y) (N) Heart Murmur/Heart Disease (Y) (N) Brain Injury (Y) (N) Hemophilia/Blood Disorders (Y) (N) Bruising (Y) (N) Hepatitis (Y) (N) Cancer/Malignancy (Y) (N) HIV/AIDS (Y) (N) Canker Sores/Cold Sores (Y) (N) Kidney Problems (Y) (N) Cerebral Palsy (Y) (N) Learning Problems (Y) (N) Chemo/Radiation Therapy (Y) (N) Liver Problems (Y) (N) Cystic Fibrosis/Lung Problems (Y) (N) Premature Birth (Y) (N) Diabetes (Y) (N) Rheumatic Fever (Y) (N) Down Syndrome (Y) (N) Tuberculosis (Y) (N) Earaches/Chronic Infections (Y) (N) Other (Y) (N) If you answered yes to any of the questions above, please explain Does your child have Allergies to any of the following? (Please check all that apply) Medications Latex/Rubber Anesthetic Pollen/Dust Foods Animals (Dogs/Cats) Acrylics Dyes/Coloring Seasonal Other
Has your child had any unfavorable reactions to drugs, anesthetics, or antibiotics? (Y) (N) Is your child currently taking any MEDICATIONS? (Y) (N) Has your child ever been HOSPITALIZED? (Y) (N) Has your child ever had any SURGERIES? (Y) (N) Are your child s immunizations up to date? (Y) (N) Is your child taking any supplemental fluoride? (Y) (N) If so, how? Dental History Is this your child s first dental visit? (Y) (N) If no, Name of Previous Dentist Phone # Date of Last Visit How was his/her experience? Were Radiographs (x-rays) taken? (Y) (N) Has your child had any injuries to their teeth, mouth, or head? (Y) (N) If yes, please describe Does your child have any of the following habits? (past or present) (Please check all that apply) Thumb/Finger sucking Pacifier Teeth Grinding Bottle-Feeding Snoring Mouthbreathing Nail Biting Lip Sucking Seasonal Does your child currently use a bottle? (Y) (N) If Yes, how many times per day? Is the bottle used at night? (Y) (N) What do you put in the bottle? Does your child currently nurse? (Y) (N) How often does your child brush his/her teeth per day? Do you help? (Y) (N)
How often does your child floss? Do you floss your child s teeth? (Y) (N) Has either parent or the child ever been treated with Orthodontics before? (Y) (N) How can we make this a positive experience for your child today? I understand that the information I have given is correct to the best of my knowledge and it is my responsibility to inform the office of any changes in my child s health status. I authorize the dental staff to perform any necessary dental services my child may need. I also authorize the dentist to release any information including the diagnosis and the records of the treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. Parent/Guardian Signature: Date: / / Doctor s Signature: Date: / /
Insurance Information Primary Insurance Company Phone # Policy Owner s Name Relationship to Child Birthdate: / / SSN: - - Group # Secondary Insurance Company Phone # Policy Owner s Name Relationship to Child Birthdate: / / SSN: - - Group # As a courtesy to our patients, we will file your insurance claim with the insurance company listed above for treatments your child receives. However, in the event the insurance company, for any reason, does not pay, the balance will become your responsibility, and will be billed directly to you. You understand that this contract is with Lamorinda Tooth Buds and yourself, and you are responsible for all charges on the account. By signing this form I am accepting all responsibility for full payment of services rendered regardless of insurance coverage. I further understand that all payments are due and payable on the day services are rendered. Signature of Responsible Party: Date: / /
Informed Consent for New Patients Please complete this Informed Consent for New Patients and initial all items as requested. Patient s Name Parent/Guardian Name: EXAM and CLEANING: Regular exams and cleanings play an important role in proper dental health. They allow the dentist to screen for dental caries, gingival and/or periodontal issues or orthodontic needs. A cleaning, fluoride treatment, x-rays and exam are performed. Risks include but are not limited to: sensitivity or bleeding of the teeth or gums due to scaling. I understand that if I choose not to maintain regular check-ups and/or cleanings, this decision may result in decay, pain, infection, and/or orthodontic or periodontal problems. X-RAYS: X-rays are used as an important diagnostic tool for the dentist. How often x-rays are taken depends on the age, risk for disease, and signs and symptoms of the patient. Our office follows the recommended guidelines from the FDA and the American Academy of Pediatric Dentistry. Many diseases of the teeth and surrounding tissues cannot be seen when your dentist examines your mouth visually. An x-ray may reveal the presence of small cavities between the teeth, infections in the bone, abscesses, cysts, developmental abnormalities and some types of tumors. It is in your child s best interest to be periodically screened with the use of diagnostic x-rays. Risks of not taking x-rays include but are not limited to: a failure to diagnose and treat conditions before signs and symptoms have developed than can threaten oral and general health. Risks from radiation exposure have been significantly reduced by improvements in technology. The benefits of dental x-rays to promote adequate and quick diagnosis outweigh the potential adverse effects. I understand if I choose to not allow x-rays to be taken, I may be asked to transfer my child to another dentist. FLUORIDE: Fluoride is a naturally occurring element that prevents tooth decay systemically when ingested during tooth development and topically when applied to erupted teeth. Topically applied fluoride provides local protection on the tooth surface. Topical fluorides include toothpaste, mouth rinses and professionally applied gels and rinses. In addition to their use in caries prevention, topical fluorides may be used to control established carious lesions. Systemic fluorides are those that are ingested into the body and became incorporated into forming tooth structures. Benefit: Fluoride helps to prevent tooth decay by making teeth stronger. Fluoride can be applied topically, in which case a gel, paste, rinse, or solution is placed on the teeth where fluoride acts directly on the tooth enamel. The application of concentrated fluoride solutions or gels may result in a reduction of dental caries. The alternative is conventional methods of dental caries prevention at home: brush twice daily with fluoride toothpaste, floss and avoid frequent snacking. Fluoride is the most effective caries-prevention agent available today. It is considered safe when properly used. The ingestion of high concentrations can lead to nausea, vomiting, dental fluorosis, which is a chalky white to brown discoloration of the permanent teeth. The complications or overdose may require medical assistance or hospitalization and even death. Consequences of not performing treatment: being deprived of the benefit of topical fluoride application and its property to prevent tooth decay and control the cavities already present. PHOTOS/VIDEOS: Lamorinda Tooth Buds occasionally takes pictures and videos of patients during their dental visit. We share these pictures by displaying them on our photo board in the office, newsletters, Facebook, and other similar websites. No personal information is shared (i.e. names, phone numbers, addresses, etc.). I give authorization to Lamorinda Tooth Buds to take pictures/videos of my child and display them in the office, newsletters, Facebook, and other similar websites. I understand that dentistry is not an exact science; therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized. I have had the opportunity to read this form and to ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment. Parent/Guardian Signature: Date: / / Witness (Doctor or Staff): Date: / /
Acknowledgment of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of the Lamorinda Tooth Buds Notice of Privacy Practices. [Please Print Name] [Signature] [Date] If this Acknowledgment is signed by a personal representative on behalf of the patient, complete the following: Personal Representative's Name Relationship to Patient For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice 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)