Patient Information for a Minor Patient

Personal Information 

Date:
Patient's name:   
Patient's nickname:
Patient resides with: Both Parents   Mother   Father   Step-Parent   Shared Custody   Guardian
Address:      
Home phone:      Gender:  Male  Female
Date of Birth:      Age: 
School:      Hobbies / Sports: 
Names & ages of other
children in your family:

How did you hear about
our office?


Responsible Party Information
(Person accompanying child to most appointments, making treatment decisions, and is financially responsible)

Name:   
Date of Birth:       SSN:       Relationship to Patient: 
Address (if different from above)     
Home phone:       Cell phone: 
Work phone:        Email: 
Is the Responsible Party the patient's legal guardian?     Yes  No
Check all that apply:  I prefer to receive  Text or Email for  Appointment Reminders Practice Newsletter

Other Guardian Information
(Other parent or step-parent, insurance subscriber, or person occasionally accompanying patient to appointments)

Name:   
Date of Birth:       SSN:       Relationship to Patient: 
Address (if different from above):       
Home phone:       Cell phone: 
Work phone:        Email: 

Emergency Contact:       Phone:       Relationship: 


Dental Benefit Plan Information

Primary dental plan name: 
Address:       
Name of insured:       Date of Birth: 
ID number:       Policy number: 
Insured's employer:       Patient relationship to insured: 
Secondary dental plan name: 
Address:       
Name of insured:       Date of Birth: 
ID number:       Policy number: 
Insured's employer:       Patient relationship to insured: 

Photograph / Media Authorization
I hereby give my consent for Dr. Allen Job and All Smiles Pediatric Dentistry to take photographs, slides and/or video of my child(ren). I also grant permission to reproduce, print and/or publish these images for use in social and internet media, marketing, advertising, articles, and lectures.

I do not expect compensation, financial or otherwise, for the use of these images.

Please initial ONLY ONE:

I consent to the use of my photographs, slides, and/or video for articles, lectures, marketing, advertising, and social media.
I consent to the use of my photographs, slides, and/or video ONLY for office use.
I DO NOT consent to the use of my photographs, slides, and/or video.

I understand that the information disclosed under this authorization may be subject to re-disclosure and no longer protected by the federal privacy regulations. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. Finally, I understand that I may revoke this authorization in writing at any time by sending a letter to my dental care provider stating my revocation and the effective date, except to the extent that action has been taken in reliance on this authorization.


Financial and Office Policy
Thank-you for joining our Practice! We are committed to providing you and your child with the best possible care. Toward this goal, we would like to explain your financial and scheduling responsibilities with our practice.

Office Surveillance Acknowledgment:  I acknowledge that video surveillance is conducted on the premises of All Smiles Pediatric Dentistry. I understand that this video surveillance is conducted in all dental treatment areas, business areas, and children’s play areas only at present. All Smiles Pediatric Dentistry retains ownership of video surveillance records as permanent records and does not include transfer of this video recording when transferring dental records to any other medical or dental provider, insurance company, or to parent/legal guardian. This video surveillance may be viewed and monitored at any time by authorized persons for the purpose of staff training, verification of compliance with employment policies of All Smiles Pediatric Dentistry, for purposes of legal proceedings, or to investigate misconduct.

Payment:  Payment is due at the time services are rendered. We accept the following forms of payment: Cash, Master Card, Visa, Discover, and checks. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice when necessary.

Insufficient Funds Fee:  A $25.00 returned check service charge for the first returned check, and a $35.00 charge for each subsequent returned check by the same payer will be assessed as well as any treble damages.

Dental Benefit Plans:  Your dental benefit is a contract between you, or your employer, and the dental plan. Benefits and payments received are based on the terms of the contract negotiated. We are happy to help our patients with dental benefit plans to understand their coverage.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this, and you will be responsible for the difference. All Smiles Pediatric Dentistry, Allen Job, DDS is a contracted provider for MetLife, Delta Dental, Guardian, Cigna, and Principal.

If we are not a contracted provider with your dental benefit plan, it is the insured’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. IF your plan allows, reimbursement for services, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance you are responsible, and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan, even if that amount is different than our estimated patient portion of the bill. IF you choose not to “assign benefits” to our practice, you are responsible for filing the claim and obtaining reimbursement, and will be responsible for payment to our practice before, or at the time of service.

Scheduling appointments:  We reserve time in our schedule for each patient procedure so when a patient cancels an appointment, it impacts the number of patients we are able to care for each day. To maintain the utmost service for all our patients, we do require 24-hours’ notice to cancel or reschedule an appointment. With less than 24-hour notice, a fee of $50.00 may be required. We do understand emergencies arise, and ask that you notify us as soon as possible.


Authorizations

I have read and completed the patient information, photo/media authorization, and financial & office policies information above and agree to these terms. (Initial)
I authorize the team to perform any necessary dental services that my child may need and have consented to during diagnosis and treatment discussions. (Initial)
I authorize the release of information necessary to process my dental benefit claim and I authorize payment to be made directly to All Smiles Pediatric Dentistry for services rendered. (Initial)
I have received a copy of this office’s Notice of Privacy Practices and have had the opportunity to ask questions regarding this policy. (Initial) (Click here to view our complete Financial & Office Policy)
I agree that the dental practice may communicate with me electronically with the provided email address. I am aware that there is some levels of risk that third parties might be able to read unencrypted emails. (Initial)


Print Responsible Party Name:  

Signature of Responsible Party (Use mouse, stylus or finger to sign):