Please fill out front and back of all forms with as much accuracy as possible.
This form must be completed by a parent or legal guardian (if legal guardian papers must be presented).
Child’s Information:
Full Name _________________________________________
Date of Birth ______/_____/______
Preferred name ______________________________
Sex _____ Social Security # _______-____-_______ Race _______________
Patient’s Address _________________________________________________________________________________
City
State
Zip
School Attending ______________________________________________ Grade ____________________________
Were you referred? If so, by whom? __________________________ Siblings seen in Office ____________________
Party Responsible for Account: Parent or Legal Guardian Not Insurance Company
Full Name _____________________________________________ DOB _______/_______/_______ Sex ________
Parent’s Marital Status (please circle one) Single / Married / Divorced / Seperated / Widowed / Other
Would you like to receive appointment reminders by text message? YES / NO
If yes, please list cell number (_____)_____-_________
Please list service provider. Verizon/ Corr Wireless/ Other please list:___________________
Father’s Information:
Parent/Guardian
Step-Father
Name _____________________________________________________________
Last
First
Middle Initial
Date of Birth _____/_____/_____
Mailing Address ___________________________________________________________________________________
City
State
Zip
Home Phone # (____)_____-______ Cell Phone # (____)_____-______ Driver’s License #____________________
Social Security # _______-_____-_______
Mother’s Information:
Name of Employer _____________________________________
Parent/Guardian
Step-Mother
Name ______________________________________________________________ Date of Birth ____/_____/_____
Last
First
Middle Initial
Mailing Address ___________________________________________________________________________________
City
State
Zip
Home Phone # (____)_____-_______ Cell Phone # (____)____-_______ Driver’s License #_____________________
Social Security #_______-_____-________
Name of Employer _____________________________________
Nassetta Pediatric Dentistry, LLC
Patrick C. Nassetta, DMD
Patient Name _______________________________________ Date of Birth ______/______/______ Sex _________
Dental History:
1) Please check reason(s) for seeking dental care:
First Cleaning & Exam
Toothache or swelling
Crowding of teeth
Possible cavity
Appearance of teeth
Accident
2) Has your child ever been seen by a dentist?
Yes
No
When? ____________ What dentist? ____________________ For what reason? __________________________
3) Do you help your child brush his/her teeth?
Yes
No
4) How often do your child’s teeth get brushed?
Not daily
AM
PM
After snacks
5) Does your child floss regularly?
Yes
No
6) What type of toothpaste do you use?
Fluoride free (i.e.- training or safe to swallow)
Fluoride (i.e.-Colgate or Crest kids)
7) Does your child drink/eat anything after brushing at night?
Yes
No
a) If yes, what? ________________________________________________
8) What does your child drink most often?
Water
White Milk
Strawberry Milk
Juice
Sodas
Kool-aid
Crystal Light
Chocolate Milk
Gatorade/Powerade
Tea
Capri Sun
Other_________
9) Does your child have snacks in between meals?
Yes
No
10) Does your child have any of the following habits?
Thumb/finger sucking
Pacifier
Mouth breathing
Lip biting or sucking
Other
Medical History:
11) Who is your child’s primary care physician? _________________________ Date of last visit: ________________
What was the visit for?_____________________________________________________________________________
12) Are your child’s immunizations up to date at this time?
Yes
No
13) Does your child see any specialists, if so, who and where?
Yes
No__________________________________
14) Has your child been a patient in the hospital? If yes, what for and when?
Yes
No _____________________
_____________________________________________________________________________________________
15) Has your child had any surgeries (i.e. tubes, tonsils, adenoids)?
Yes
No _____________________________
16) Is your child currently taking medications?
Yes
No
If yes, please list: ______________________________________________________________________________
17) Does your child have allergies to foods, drugs, or other?
Yes
No
Please list: ___________________________________________________________________________________
18) Please mark Yes or No if your child has/had problems with the following:
Liver
Heart
Autism
Asthma
Yes / No
Yes / No
Yes / No
Yes / No
Kidney
Speech
Cancer
Diabetes
Yes / No
Yes / No
Yes / No
Yes / No
Epilepsy Yes / No
Bleeding Yes / No
ADD/ADHD Yes / No
Hepatitis Yes / No
Cerebral Palsy
Respiratory Disease
Emotional Problems
Mental Retardation
Yes / No
Yes / No
Yes / No
Yes / No
Other Yes / No - Please Explain: _____________________________________________________________________
X Signed __________________________________ Relationship to Patient______________Date ___/____/___
PLEASE SEE REVERSE SIDE
Nassetta Pediatric Dentistry, LLC
Patrick C. Nassetta, DMD
1705 Main Ave SW, Suite A
Cullman, AL 35055
(256) 739-6000
Fax (256) 739-6009
Insurance Benefit Disclaimer
We file your insurance as a courtesy for you. This is not a guarantee that the insurance company will pay us
or send payment directly to you. The insurance companies pay at their discretion. We have no control over
what procedures or amounts they chose to pay.
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The procedures that we do are in accordance with those recommended by the American Academy of
Pediatric Dentistry.
The procedures that are preformed are those which benefit the oral health of your child and are not
influenced by insurance company reimbursement.
If you have any reservations about treatment pricing please address these with Dr. Nassetta prior to
treatment.
Insurance companies pay on what they have set as their fee schedule and that varies per insurance
company. (Example: Most cleanings or dental procedures are paid at 100% of their fee schedule not
100% of the actual charged fee by the dentist).
You are responsible for any insurance checks that are sent directly to you by forwarding them to us. If
they are not received in a timely manner (within 30 days) the balance becomes your
responsibility.
We are only a preferred provider for Medicaid, All-Kids, and BCBS of Alabama; however, we will accept
and file for you most major insurances.
If at any time you are not certain what benefits are covered by your insurance company, we ask that
you refer to your coverage booklet provided by your insurance company through your employer.
We try to verify all active coverage prior to treatment being preformed. Should your coverage become
retroactively cancelled or not be in effect at the time of service, the balance becomes your
responsibility.
We will work with you and your insurance company to get all the benefits that are provided for you to
the best of our ability. This may require additional information that you may submit to our office.
Alternatively, this may require you to contact your insurance company.
Appointment Cancellation Policy
We require a 24 hour notice for any cancellations. Having two missed or cancelled appointments within less
than 24 hours prior to the appointment is noted as failure to comply with policy and may result in dismissal
from our practice.
Thank you!
Treatment Consent Form
Patient Name _________________________________________________ DOB _____/______/______
We do our best to give your child the best quality dental care in a safe and caring environment.
Every effort will be made to work with your child to gain cooperation through understanding, gentle guidance,
humor, and charm. When these fail there are other techniques that can be used to eliminate or minimize
disruptive behavior. Dr. Nassetta has received training in the following techniques accepted by the American
Academy of Pediatric Dentistry. I understand that Dr. Nassetta or his assistants may incorporate such
techniques to provide preventive, diagnostic, restorative, and oral surgical procedures that are reasonable,
necessary, and advisable for this patient.
--Tell-show-do: Dr. Nassetta or staff member explains to the child what is to be done, shows an example on a tooth
model or on the child’s finger, then the procedure is done on the child’s tooth.
--Positive reinforcement: rewards the child who displays cooperative behavior with complements, praise, a pat on the
shoulder, or a small prize
--Voice control: the attention of a disruptive child is redirected by a change in the tone and volume of the dentist’s
voice.
--Mouth prop: a device is placed in the mouth to prevent closure of the child’s teeth on the dentist’s fingers or dental
equipment that could possibly harm the child
--Hand and/or head holding by dentist or assistant: an adult keeps the child’s body still so the child cannot grab
the dentist’s hand or sharp dental tools
--Nitrous oxide: medication breathed through colored/flavored nose mask to relax a nervous child. The child remains
awake but is relaxed and calm. Nitrous oxide is also known as laughing gas. Children with sensitive stomachs may
become nauseated when breathing nitrous oxide.
--Stabilization wrap: a body wrap made of fabric mesh and Velcro that is placed around the child to limit movement.
It is never used without consent of the parent.
--I hereby do authorize and request performance of dental services for this patient and the use of whatever
procedures Dr. Nassetta may deem necessary during treatment.
--Parents are welcome in the treatment area; however, we ask that only one person accompany the patient
back. During sedation appointments and in other instances in which your child may benefit from your
absence, you will be asked to remain in the waiting room.
The above behavior management techniques have been explained to me and I have had a chance to ask
questions. I understand the what, when, how and why of their use, and the risks/benefits/available
alternatives.
X Parent/Guardian _____________________________________
Date ____/______/_____
Witness ______________________________________________ Date____/______/______
I acknowledge that I have receipt of notice of privacy policies/HIPPA policies and I understand and agree
to the said policy.
X Signature ___________________________________________Date _________________
___ Responsible party refused to sign
___ An emergency situation prevented us from obtaining signature
Please complete the following information.
Emergency Contact Not Living With You (Nearest Relative):
Name __________________________________ Relationship ________________________________
Address _______________________________________________ Phone # (_____)______-_______
City
State
Zip
Dental Insurance Information (Primary):
Name of Insured Person _____________________________ DOB_____/____/____ Sex ______
Social Security # _____-____-_____ Relationship to Patient _______________
Address ________________________________________________________________
City
State
Zip
Insurance Company Name _________________________________________________
Contract # _________________________________ Group # ____________________
Employer __________________________________________ Phone #(____)______-________
Secondary Dental Insurance (If applicable):
Name of Insured Person ______________________________ DOB_____/_____/____ Sex ______
Social Security #_____-____-_____ Relationship to Patient _______________
Address ________________________________________________________________
City
State
Zip
Employer ________________________________________ Phone # (____)_______-_________
Insurance Company Name _________________________________________________
Contract # _________________________________ Group # _____________________
Authorization to file Insurance (Initial) ______________
--I understand that payment in full for services rendered is expected at the time of service. There is
no direct relationship between our office and your insurance company. The type of plan chosen by you, and/or
your employer determines your insurance benefits. As such, we have no say in the selection of your insurance
company, no control over the terms of your contract, the methods of reimbursement or the determination of
your insurance benefits. We are a preferred provider for Blue Cross Blue Shield, All Kids, and Medicaid. As a
courtesy to you, we will file your insurance even if we are not a preferred provider. If you have any questions,
please feel free to ask our office manager.
--We will accept assignment of benefits from your insurance company; however you are responsible for the full
balance including any amount that is not paid by your insurance company.
--I further agree to pay any and all collection cost, reasonable attorney fees, and court fees that become
necessary to collect any unpaid balance.
X Guarantor Signature: _______________________________________ Date: _____/____/_____