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Patient Intake Form

Financial Information

Parent 1 Information

Parent 2 Information

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
Sinusitis, chronis adenoid/tonsil infections
Sleep apnea, snoring, mouth breathing
Congenital heart defect/disease, heart murmur*, rheumatic fever/heart disease
Irregular heartbeat, high blood pressure
Asthma, Reactive Airway Disease, breathing problems
Cystic fibrosis
Frequent colds/coughs
Liver problems, hepatitis, jaundice
Gastroesophageal reflux disease(GERD), stomach ulcers, intestinal problems
Lactose intolerance or dietary restrictions
Concerns with weight loss, eating disorder
Bladder or kidney problems
Scoliosis, fine/gross motor deficits, arthritis
Eczema, rash/hives
Impaired vision, visual processing, hearing or speech
Developmental; delays, learning problems/delay
Cerebral palsy, brain injury, epilepsy, seizure, convulsions
Autism spectrum disorder
Recurrent/frequent headaches/migraines, fainting, dizziness
Syndromes/inherited conditions
Thyroid or pituitary problems
Blood disorders, anemia, sickle cell disease/trait
Hemophilia, bruising easily, excessive bleeding
Cancer, tumor, chemotherapy, radiation therapy, bone marrow or organ transplant

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

Dental History

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

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.

HIPAA Consent Form

General Information

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.


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

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.

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.