Patient Information
«LName», «FName» «MI»
Patient Name:
Last,
First
MI
Social Security #: «SS»
Address:
Date: 02/06/2016
(Preferred Name)
Birth Date:
«BirthDate» Phone (Home): «HPhone» Gender: Female
«Street»
Street
«Street2»
«City»
«State»
Apartment #
City
State
«Zip»
Zip Code
Referral Information
Whom may we thank for referring you to our practice?
Dental Office
Yellow Pages
Another patient
Insurance Company
School
Advertisement _________________________
Name of person/office: «RefBy_Name»
Mother (or Guardian) Information
Guarantors Name: ____________________________
Male
Female
Married
Single
Other _________
Social Security #: ________________________________ Birth Date:_________/________/__________
Phone (Home): _«HPhone»__ (Work): _______________Ext: ______ (Cell): _______________
If address is the same as child please check here
Address: ____________________________________________________________________________________________________
Street
Apartment #
City
State
Zip Code
Employer: _____________________________________________ Email: ____________________________________________
Father (or Guardian) Information
Guarantors Name: _____________________________
Male
Female
Married
Single
Other __________
Social Security #: ________________________________ Birth Date:________/________/___________
Phone (Home): _«HPhone»__ (Work): _______________Ext: ______ (Cell): _______________
If address is the same as child please check here
Address: : ____________________________________________________________________________________________________
Street
Apartment #
City
State
Zip Code
Employer: _____________________________________________ Email: ____________________________________________
Name of Insurance Company: ________________________Policy Number:_________________________________________
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
TO THE PATIENT/ PERSONAL REPRESENTATIVE- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment
activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice
provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health
information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to
read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy
Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply
to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice,
at any time.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person
listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your
revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I have had full opportunity to read and consider the
contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and
disclosure of my child’s protected health information to carry out treatment, payment activities and healthcare operations.
FINANCIAL POLICY
Pediatric Dentistry at Vinings is committed to providing your child with the best possible dental care. Please understand that payment of your bill is
considered a part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to treatment. Payment for
all services provided by the practice is due in full at the time the services are rendered. If you have private insurance, we will file your visit. Your full copayment is expected per visit. You will be billed in full for any services that your insurance plan deems to be a non-covered service or any balances due after
we have received payment from your insurance carrier. All patient balances are payable upon receipt of the statement. We accept Cash, debit & credit
cards (Visa, MasterCard, AMEX, and Discover Card) as payment for services rendered. Personal checks are not accepted. Refunds will be handled
as a credit to the patient’s account or issued a check. Pediatric Dentistry at Vinings reserves the right to turn any patient over to collections if it is deemed
that the account has been in default of the payment obligations or compliance of this policy. You will be responsible for all collections related fees which
may represent 1/3 of the balance due.
APPOINTMENT POLICY
All our patients are seen on a reserved appointment basis. In most cases, the procedure you are scheduled for requires that a definite amount of time be set
aside with the dentist or hygienist. This assures the best possible care for your child. Every effort in scheduling is made to minimize waiting. All
appointments must be verbally confirmed with the office within the week of your appointment. The office will make every attempt to confirm your
appointment. If you must reschedule your appointment, please contact our office as soon as possible. Giving us this courtesy allows us to schedule another
patient who wishes to be seen. Appointments that are not cancelled at least 24 hours in advance will be considered a broken appointment and will
be charged a $25.00 fee. A good dentist/patient relationship is based upon understanding and good communications. If you have any questions about
financial arrangements, please feel free to speak with our Business Manager. We will make every effort available to you to clarify any misunderstanding you
may have concerning your account. We are here to help you.
I have read, understand and agree to the terms of the above Financial and Appointment Policy of Pediatric Dentistry at Vinings.
Signed: _____________________________________________________ Date: _______/_______/_________
Child’s Name «LName»,
«FName» «MI»
_____
HEALTH HISTORY
GENERAL HEALTH REVIEW Please review your child’s past and present health history. Mark the box ONLY if your child has the condition now or has been treated in the past.
THE EYES, EARS, NOSE AND THROAT
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THE LUNGS
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Allergies
Chronic Earaches
Deafness/Hearing Loss
Speech Problems
Chronic Sore Throat/Tonsillitis
Tonsils/Adenoids Removed
Blindness/Low Vision
Other
THE CIRCULATORY SYSTEM
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Asthma Date of last attack_________________
Uses inhaler as needed
Uses daily oral medicines or inhaler
Uses steroids or has used steroids
Bronchitis
Pneumonia
Tuberculosis
Other ___________________________________
THE NERVOUS SYSTEM, MUSCLES AND BONES
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Heart Murmur
Antibiotics for previous dental work
Circulation Problems
Congenital Heart Problems
Heart Surgery
Artificial Heart Valve
Rheumatic or Scarlet Fever
Excessive Bleeding/Hemophilia
Hepatitis
Sickle Cell Anemia
HIV/AIDS
Leukemia
History of Blood Transfusion Date___________
Other
Epilepsy or Seizure
Fainting
Cerebral Palsy
Nervous Problems
Mental retardation
Down Syndrome
Autism
Attention Deficient Disorder
Head Trauma/Brain Injury
Spina Bifida
Muscular Dystrophy
Orthopedic Problems
Artificial Joints
Other
THE STOMACH, LIVER, KIDNEYS, BLADDER
 Stomach Problems
 Diabetes
 Kidney Problems
 Hepatitis
 Bladder Problems
 Other
ALLERGIES
 Allergy to food, food additives
 Allergy to household items, dust, pets
 Allergy to plants, pollen, grass
 Allergy to latex rubber
 Allergy to Drugs. Specify
 Other
INFECTIONS AND SERIOUS ILLNESSES
 Immunizations are up-to-date
 Chicken Pox
 Chemotherapy Date(s)
 Hospitalization. Date(s)
 Cancer or other malignancies
Type
 Psychological problems, testing or counseling
GROWTH AND DEVELOPMENT
 Prematurely or complicated pregnancy
 Birth defects
 Concerns with growth
 Learning, behavioral, or communication problems
 Alcohol, tobacco, or drug use
LIST ANY MEDICATIONS YOUR CHILD IS PRESENTLY TAKING: __________________________________________________________________________________
IS THERE ANYTHING ELSE WE NEED TO KNOW ABOUT YOUR CHILD’S HEALTH HISTORY?
Pediatrician
Phone #
(
)
________________________________________
____ _-
______
DENTAL HEALTH AND HABITS
Please mark only the boxes that apply to your child.
 MY CHILD HAS HAD REGULAR DENTAL EXAMS AND CLEANINGS. DATE OF LAST DENTAL APPOINTMENT: _______/________/__________
 MY CHILD PRESENTLY TAKES A FLUORIDE SUPPLEMENT
 DENTAL X-RAYS WERE TAKEN AT EARLIER VISITS WITH DR.
 MY CHILD WAS BREAST OR BOTTLE FED FOR MORE THAN 1 YEAR
 MY CHILD SLEPT WITH A BABY BOTTLE. (What was in the bottle?
___________
)
 MY CHILD SUCKS A THUMB OR FINGERS.OR A PACIFIER (Please circle)
 MY CHILD IS A MOUTH BREATHER
 MY CHILD GRINDS or CLINCHES TEETH.
 INJURY TO MOUTH AND/OR TEETH.
 BLEEDING GUMS
 ARE THERE ANY OTHER DENTAL CONCERNS TO YOU AS A PARENT? ___________________________________________________________________________
FIRST VISIT INFORMATION (only new patients and their parents need to complete this section)
 THIS IS MY CHILD’S FIRST DENTAL VISIT.
 MY CHILD IS WORRIED ABOUT TODAY’S VISIT
 MY CHILD’S PREVIOUS VISITS WERE UNSATISFACTORY.
 MY CHILD HAD AN ACCIDENT, HURTING THE HEAD, MOUTH, OR TEETH
 MY CHILD HAS HAD A TOOTHACHE RECENTLY? (Please circle) When eating only or Keeps him/her up at night
WHAT IS THE FAMILY’S WATER SUPPLY? (Please circle) Well or Public system or Bottled/distilled
HOW OFTEN ARE YOUR CHILD’S TEETH BRUSHED PER DAY? (Please circle) ONCE or TWICE or AFTER EACH MEAL or NONE
WHAT TYPE OF TOOTHPASTE DOES YOUR CHILD USE? ______________________________________ DO YOU HELP YOUR CHILD FLOSS DAILY? Yes or No
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