Chelsea Pediatric Dentistry and
Orthodontics 950 Broadway Unit 1C,
Chelsea, MA 02150 Phone: (617) 8895437
Fax: (617) 889-5435
E-mail: contact@chelseakiddentist.com
Dr. Ashka Soni, DMD
Dr. Vandana Soni, DMD
Hobbies, Sports, and Interests _____________________________________________________
Gender
_________
Welcome! Please take a few moments to tell us a little about your child so that we may assist you in taking the very
best care possible of him/ her. On the first visit it is permissible for you to come back with your child. However, we have
found that children do better on subsequent visits if their parents remain in the waiting room.
HEALTH HISTORY
PHYSICIAN'S NAME.
. ATE OF LAST MEDICAL EXAM ____________CHILD'S AGE _______
D
PHYSICIAN'S PHONE NUMBER _____________________
YES
NO
YES
☐
☐ Allergy to Penicillin/ Amoxicillin
☐ ☐ Blood Transfusion
☐
☐
☐ Allergies to Other Drugs_____
☐ Allergies to Local Anesthetics
☐
☐ Allergies to Latex or Metals
☐
☐ Heart Murmur, Defect or Surgery
YES
NO
NO
☐ ☐ Kidney Problems
☐ ☐ Cancer
☐ ☐ Leukemia
☐ ☐ Cerebral Palsy
☐ ☐ Liver Problems, Hepatitis
☐ ☐ Chemotherapy I Radiation
Handicap
☐ ☐ Mental or Physical
☐ ☐ AIDS/HIV
☐ ☐ Child Abuse
☐ ☐ Premature Birth
☐
☐ Anemia -Blood Problems
☐ ☐ Developmentally Delayed
☐ ☐ Rheumatic Fever
☐
☐ Asthma
☐ ☐ Emotional Difficulties I Psychiatric Care ☐ ☐ ☐ Sickle Cell
☐ ☐ Diabetes
☐
☐
☐ ☐ Eye Problems
☐ Epilepsy, Seizures,
☐ Extreme Nervousness or Apprehension
☐☐ Thyroid disorders
Convulsions
☐ ☐ Sinus Problems or General Allergies
☐
Autism
☐ ☐ Hearing I Speech Problems
☐ Birth defects
☐ ☐ Hyperactivity (ADD/ADHD)
☐
☐
☐ ☐ Syndrome_____
☐ ☐ Tonsillitis
☐ ☐ Tuberculosis
☐☐ Ulcer or colitis
☐☐Other
☐ Bleeding problems:Hemophilia
☐
Medications
_
Hospitalizations: Age and Reason: ___________________________________________________________________________
DENTAL HISTORY
DOES YOUR CHILD HAVE ANY DENTAL PROBLEMS AT THIS TIME?
DATE OF LAST DENTAL EXAM
ANY UNFAVORABLE DENTAL EXPERIENCE, ☐ YES
_
☐ NO
PLEASE EXPLAIN _______________________________________________________________________________________________
DOES THE CHILD HAVE OR USE ANY OF THE FOLLOWING- INDICATE WITH A CHECK MARK
Traumatic injury to mouth or teeth
☐ Bleeding gums, How long,
_
☐ Pain on ear
☐ Frequency of brushing by child /day
☐ Bad breath
☐ Frequency of brushing by parent
☐ Clenching or grinding of teeth
☐ Orthodontic treatment
☐ Dental Floss
☐ Swelling or lumps in mouth
☐ Mouth breathing
☐Fluoride
☐ Frequent blisters on lips or mouth
☐ Oral habits; thumb sucking,
fingernail biting, cheek biting,
etc.
supplements
☐ Teeth sensitive to cold, heat, sweets
or pressure
☐
Between
/day
meal
snacks
☐ Well balanced diet
APPOINTMENTS: Please realize we have reserved time especially for your child. If for some reason you must cancel your child’s
appointment we expect 24 hours’ notice (weekends not included).
INSURANCE: To avoid misunderstandings regarding dental insurance, we wish the persons responsible to know that all professional services
rendered are charged to them and that they are personally responsible for payment of fees. As a courtesy to you we will prepare necessary forms or
reports to help the persons responsible obtain benefits from insurance companies. Any questions concerning insurance benefits should be directed to
the insurance company's representative or benefits office. The deductible and/ or co-payment is expected at the time of service. We do not render our
services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient.
CONSENT: Dr. Ashka Soni, Dr. Vandana Soni & their associates and/or their staff are authorized to Perform such dental and related surgical or medical
treatments as deemed necessary and that all risks and treatments will be explained as needed.
I have read the above and to the best of my knowledge the information is correct.
I have reviewed the treatment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit
plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent
permitted under applicable law, I authorize release of any information relating to my child's treatment.
I hereby authorize payment of the dental benefits otherwise payable directly to Dr. Ashka Soni, Dr. Vandana Soni & Associates.
SIGNATURE _________________________
DATE _____________
PARENT OR GUARDIAN __________________________________
Effective Date: September 21 st 2013
Dr. Ashka & Vandana Soni
PRIVACY PRACTICE
It is the policy of our practice that all physicians and staff preserve the integrity and the confidentiality of protected
health information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our practice and its
physicians and staff have the necessary medical and PHI to provide the highest quality medical care possible while
protecting the confidentiality of the PHI of our patients to the highest degree possible. Patients should not be afraid to
provide information to our practice and its physicians and staff for purposes of treatment, payment and healthcare
operations (TPO). To that end, our practice and its physicians and staff will -
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Adhere to the standards set forth in the Notice of Privacy Practices.
Collect, use and disclose PHI only in conformance with state and federal laws and current patient
covenants and/or authorization, as appropriate. Our practice and its physicians and staff will not
use or disclose PHI for uses outside of practice's TOP, such as marketing, employment, life insurance
applications, etc. without an authorization from the patient.
Use and disclose PHI to remind patients of their appointments only within their consent.
Recognize that PHI collected about patients must be accurate, timely, complete, and available
when needed. Our practice and its physicians and staff will:
o Implement reasonable measures to protect the integrity of all PHI maintained about patients.
Recognize that patients have the right to privacy. Our practice and its physicians and staff respect
the patient's individual dignity at all times. Our practice and its physicians and staff will respect
Patient’s privacy to the extent consistent with providing the highest quality medical care possible
and with the efficient administration of the facility.
Act as responsible information stewards and treat all PHI as sensitive and confidential.
Consequently, our practice and its physicians and staff will:
o Treat all PHI data as confidential in accordance with professional ethics, accreditation
standards, and legal requirements.
o Not disclose PHI data unless the patient (or his or her authorized representative) has properly
Consented to/ or authorized the release or the release is otherwise authorized by law.
Recognize that, although our practice "owns" the medical record, the patient has a right to inspect
and obtain a copy of his/her PHI. Our practice and its physicians and staff will:
o Permit patients access to their medical records when their written requests are approved
by our practice. If we deny their request, then we must inform the patients that they may
request a review of our denial. In such cases, we will have an on-site healthcare professional
review the patient's appeals.
All physicians and staff will maintain a list of all disclosures of PHI for purposes other than TPO
for each patient. We will provide this list up request in writing.
All physicians and staff will adhere to any restrictions concerning the use or disclosure of PHI
that patients have requested and have been approved by our practice.
All physicians and staff must adhere to this policy. Our practice will not tolerate violations. Violation
of this policy is grounds for disciplinary action, up to and including termination of employment and
Criminal or professional sanctions in accordance with our practice's personnel rules and regulations.
Our practice may change this privacy policy in the future. Any changes will be effective upon the
Release of a revised privacy policy and will be made available upon request.
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICE
Chelsea Pediatric Dentistry and Orthodontics
950 Broadway Unit 1C, Chelsea, MA 02150
** You may refuse to sign this Acknowledgement**
I,
(Please print your name)
have received a copy of this office's Notice of Privacy Practices.
(Signature)
(Date)
Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,
but acknowledgement could not be obtained because:
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Individual refused to sign
Communications barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Other (Please Specify)