Patient Intake Form

Child's Legal Name

Preferred Name

Date of Birth

Child's Age

What does your child identify as?

Address

City

State

Zip Code

Have your brothers and sisters been seen in this office? If yes, Name & Ages of Brothers & Sisters

Who shall we thank for referring you to our office?

Primary Physician

Medical Specialist

Date of last Medical Exam

Are all immunizations up to date?

Is your child taking any medications (prescription or over the counter) including fluoride vitamins?

If so, please list name, dose and frequency

Has your child ever had any unusual reactions to any medications? If so, please explain.

Financial Information

Parent 1 Information

Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth

Social Security #

Employer

Employer Address

City

State

Zip

Work Phone

Dental Insurance

Group #

ID #

Primary

Secondary

Parent 2 Information

Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth

Social Security #

Employer

Employer Address

City

State

Zip

Work Phone

Dental Insurance

Group #

ID #

Primary

Secondary

Medical History

Please mark YES if your child has a history of the following conditions. For each “YES” please provide details in the box below. Mark NO after each condition if it does not apply to your child.

Any known allergies

Yes

If so, please specify:

Sinusitis, chronis adenoid/tonsil infections

Yes

Sleep apnea, snoring, mouth breathing

Yes

Congenital heart defect/disease, heart murmur*, rheumatic fever/heart disease

Yes

Irregular heartbeat, high blood pressure

Yes

Asthma, Reactive Airway Disease, breathing problems

Yes

Cystic fibrosis

Yes

Frequent colds/coughs

Yes

Liver problems, hepatitis, jaundice

Yes

Gastroesophageal reflux disease(GERD), stomach ulcers, intestinal problems

Yes

Lactose intolerance or dietary restrictions

Yes

Concerns with weight loss, eating disorder

Yes

Bladder or kidney problems

Yes

Scoliosis, fine/gross motor deficits, arthritis

Yes

Eczema, rash/hives

Yes

Impaired vision, visual processing, hearing or speech

Yes

Developmental; delays, learning problems/delay

Yes

Cerebral palsy, brain injury, epilepsy, seizure, convulsions

Yes

Autism spectrum disorder

Yes

Recurrent/frequent headaches/migraines, fainting, dizziness

Yes

ADD/ADHD

Yes

Syndromes/inherited conditions

Yes

Diabetes

Yes

Thyroid or pituitary problems

Yes

Blood disorders, anemia, sickle cell disease/trait

Yes

Hemophilia, bruising easily, excessive bleeding

Yes

Cancer, tumor, chemotherapy, radiation therapy, bone marrow or organ transplant

Yes

TB, MRSA, STD, HIV/AIDS, CMV

Yes

*NOTE: It is very important for the health of your child that medical clearance for heart murmur/disease be documented.

Please provide details here:

Dental History

What is your primary concern about your child’s oral health?

Is there a family history of cavities?

How often does your child brush their teeth?

How often does you child floss their teeth?

Is your child on a restricted diet?

If yes, describe

Was your child breast fed?

Was your child bottle fed?

To what age?

Does/Did your child fall asleep with a bottle or while nursing?

Has your child been examined by another dentist?

If yes, DATE?

Were x-rays taken?

Has your child ever had a difficult dental appointment?

Has your child experienced any major injury to the face or jaw?

If yes, describe:

How do you expect your child will respond to dental treatment?

Very well

Fairly well

Somewhat poorly

Very poorly

Consent For Treatment

I certify that the above information is true and correct. I give my consent for my child to be examined and receive dental treatment as the dentist deems fit after consultation with the parent/guardian.

Patients who carry dental insurance understand that all dental services rendered are charged directly to the patient and that he/she is personally responsible for payment of all dental services.

A service charge of 1.5% per month (18% annual) on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial agreements are satisfied.

A $75 fee will be incurred for missed appointments without 24 hour notice.

I understand that payment is expected for services at the time it is rendered unless previous arrangements have been made or within five (5) days of billing if credit shall be extended.

I grant permission to your assignee to telephone me at home or work to discuss matter related to this form.

Signature

Date

Relationship to patient

HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

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 operation.

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.

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 by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a 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 of 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.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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