Sunny Smiles Pediatric Dentistry

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Transcription:

Sunny Smiles Pediatric Dentistry Patient: Tday s Date: Nickname/Preferred Name: Date f Birth: Age: Sex: M F Schl: Grade: Hme Address: City: Zip: Phne Number: Scial Security Number: Wh has legal custdy f this patient? Hw did yu hear abut ur ffice? Reasn fr tday s visit: MOTHER S INFORMATION: Name: Date f Birth: Emplyer: Scial Security Number: Wrk Phne #: Hme Phne #: Cell Phne #: FATHER S INFORMATION: Name: Date f Birth: Emplyer: Scial Security Number: Wrk Phne #: Hme Phne #: Cell Phne #: PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT: Name: Relatinship t Patient: Billing Address: City: Zip: Wrk Phne #: Hme Phne #: Cell Phne #: E mail address: INSURANCE INFORMATION Dental Insurance Cmpany: Grup #: Phne #: Name f Insured:

Physician s Name: Phne #: Date f last physical: Please list any knwn allergies: Please list all current medicatins this patient is taking, including the reasn fr taking the medicatin: Des yur child need pre medicatin with antibitics befre dental appintments? Has yur child ever been hspitalized? If yes, please describe when and why: Has yur child ever been treated in the emergency rm? If yes, please describe when and why: Has yur child ever had surgery? If yes, please describe when and why: Has yur child ever been diagnsed with r treated fr the fllwing? ADHD/Hyperactivity Breathing Prblems Heart Murmur Premature Birth Allergies Cancer/Tumr Hepatitis Rheumatic Fever Anaphylactic Shck Cerebral Palsy High Bld Pressure Seizures/Epilepsy Anemia Cleft Lip/Palate HIV/AIDS Sleep Apnea Arthritis Delayed Speech Kidney Disease Sickle Cell Disease Artificial Jints Develpmental Delay Latex Sensitivity Sinus Prblems Asthma Diabetes Liver Disease STD Birth Defects Fainting Spells Lw Birth Weight Tnsillectmy Bladder Disease Head/Neck Injury Mental/Nervus Disrder Tuberculsis Bleeding Prblems Hearing Impairment Pacemaker Visin Prblems Bld Disrder Heart Cnditin Pregnancy Other If ther, please specify: Please elabrate n any f the abve marked yes: When was yur child s last dental visit? Previus dentist s name and address: Why did yur child leave his/her previus dentist? When were X rays last taken f yur child s teeth? D yu have any cncerns regarding his/her teeth? Des yur child clench r grind his/her teeth? Des yur child have any tth, jaw, r muscle discmfrt? Des yur child have frequent headaches? Des yur child have a click, pp, r ther nise in the jaw jint? Are yur child s teeth sensitive t ht r cld? Are any f yur child s teeth uncmfrtable fr him/her when he/she bites? D yur child s gums bleed when brushing r flssing?

Des yur child have any cncerns abut the appearance f his/her teeth? Des yur child have a histry f an accident r injury invlving the teeth/jaws? Des yur child get cld sres r canker sres? Des yur child have a habit f snring r muth breathing? Des yur child have a current r previus habit invlving a pacifier r thumb/finger sucking? Des yur child have a histry f ging t sleep with a baby bttle r n demand breast feeding? Des yur child frequently eat sweets and/r drink juices r sdas? Des yur child nly drink bttled, highly filtered, r well water? D yu supervise r assist yur child in brushing his/her teeth? Des yur child use tthpaste with fluride? Des yur child use fluride tablets r rinses? Des yur child use dental flss? Hw has yur child reacted t previus medical r dental prcedures? Hw d yu expect yur child t react in the dental chair? What are yur child s interests and hbbies? Please list any cnditins r cncerns regarding yur child s health that have nt been cvered in this questinnaire: I, the undersigned parent/legal guardian f this child, certify that the abve is accurate and cmplete t the best f my knwledge. I will ntify the dentist and/r the staff f any change in the abve prir t any appintment. Signature: Name: Date: Relatinship t Patient: I, the undersigned parent/legal guardian, hereby give cnsent fr the dentist and/r clinical staff t examine this child, clean his/her teeth, perfrm all necessary dental treatment, administer lcal anesthetics, administer medicatins, apply tpical fluride, take diagnstic radigraphs (X rays), take clinical phtgraphs, btain study mdels and ther recrds necessary fr an accurate diagnsis fr my child. I understand that dental treatment fr children invlves behavir guidance, which may include the use f praise, explanatin and demnstratin f prcedures and instruments, variable vice tne, muth prps, nitrus xide (laughing gas), r prtective stabilizatin when necessary t prmte cperative behavir and a psitive experience and t prtect my child frm ptential injury. Signature: Name: Date: Relatinship t Patient:

Sunny Smiles Pediatric Dentistry 8525 Dr.MLK Jr. St. Nrth St. Petersburg, FL 33702 (727) 914 6611 CANCELLATION / MISSED APPOINTMENT POLICY Our ffice strives t prvide ptimum treatment and cnvenience fr ur patients by ffering accmmdating and flexible scheduling. Therefre, we ask that yu help us by keeping yur scheduled appintments, and by ntifying ur ffice in advance if yu are unable t d s. We have a waiting list fr appintments and when given advance ntice we are ften able t accmmdate ther patients. ALL PATIENTS WHO FAIL TO ARRIVE FOR THEIR SCHEDULED APPOINTMENTS OR WHO CANCEL WITH LESS THAN 24 HOURS ADVANCE NOTICE WILL BE CHARGED A MISSED APPOINTMENT FEE Missed appintment fees are NOT cvered by insurance plans and are yur respnsibility t pay If yu need t cancel r reschedule an appintment, please give at least 24 hurs ntice t avid a charge If yu fail yur appintment and have nt ntified the ffice 24 hurs in advance yu will be charged a missed appintment fee If yu miss tw cnsecutive appintments, any remaining appintments scheduled will be cancelled and referring dentist will be ntified. Thank yu fr yur cperatin. Patient Name (please print): Signature belw indicates I have read and understand this plicy. Patient(18 r lder) r Legal Guardian Signature:

Sunny Smiles Pediatric Dental Office 8525 Dr. MLK Jr. St. Nrth St. Petersburg, FL 33702 (727) 914 6611 INSURANCE BENEFIT ACKNOWLEDGEMENT Having insurance is nt a substitute fr payment. Many cmpanies have fixed allwances r percentages based n the cntract yu have with them, nt with ur ffice. It is yur respnsibility t pay deductible, cinsurance, and any ther balances nt paid by yur insurance cmpany. In determining the amunt f benefits payable, yur insurance cmpany may give cnsideratin t an alternate prcedure that may accmplish a prfessinal satisfactry result. If an alternate benefit prvisin is applied t a prcedure perfrmed by yur dentist and submitted t yur insurance cmpany as a claim, the amunt f mney yu we yur dentist may be mre than the amunt specified n the Explanatin f Benefits (EOB). Estimates f cverage are nt a guarantee as eligibility, plicy prvisins and pssible charges frm ther ffices affect payment. Yur insurance cmpany may nt pay their full estimated prtin. YOU ARE RESPONSIBLE FOR ALL TREATMENT CHARGES NOT PAID BY YOUR INSURANCE COMPANY. I agree t pay the fees, including any deductible, c insurance, and any ther balances nt paid by my insurance cmpany, t Dental Specialty Grup f Pinellas. Signature f Patient/ Legal Guardian if patient is minr Date Patient s Name

Sunny Smiles Pediatric Dentistry Acknwledgement f Receipt f Ntice f Privacy Practices Purpse: This frm is used t btain acknwledgement f receipt f ur Ntice f Privacy Practices r t dcument ur gd faith effrt t btain that acknwledgement. **Yu May Refuse t Sign This Acknwledgement** I have been given cpy f this ffice s Ntice f Privacy Practices t review and I am aware that the ffice has a cpy f the Ntice available t take with me if I request ne. {Please Print Patient s Name} {Signature f Patient r Legal Guardian} {Date} Sunny Smiles Pediatric Dentistry may use r disclse prtected health infrmatin fr the purpse(s) f treatment, payment, cllectins, r health care peratins. We may disclse yur persnal health care infrmatin t ther dental and/r medical prfessinals relating t yur treatment, payment, r health care. If yu wish t authrize Sunny Smiles Pediatric Dentistry t release yur persnal health care infrmatin t anyne ther than fr the reasns abve, please list belw. 1. 2. 3. Fr Office Use Only We attempted t btain written prf f Infrmed Acknwledgement f Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify) 2002 American Dental Assciatin All Rights Reserved Reprductin and use f this frm by dentists and their staff is permitted. Any ther use, duplicatin r distributin f this frm by any ther party requires the prir written apprval f the American Dental Assciatin. This Frm is educatinal nly, des nt cnstitute legal advice, and cvers nly federal, nt state, law (August 14, 2002).

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