ABCDDS New Patient Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party. We are fully compliant with all HIPAA Regulations.
Note: The parent or guardian who accompanies the child is responsible for payment at the time of service.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *
/ /

Child's Full Name *

Nickname

Gender *

Siblings We Treat

Child's Birthdate *
/ /

Child's Age

School

Preferred Contact Number

Social Security Number *

Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


2. Mother's Information

Name *

Relationship to Child *

Birthdate *
/ /

Mother's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Employer

Work Number

Home Number *

Cell Number

Social Security Number *

Driver's License Number *

Email Address *


3. Father's Information

Name

Relationship to Child

Birthdate
/ /

Father's Home Address

Street Address

Apt #

City

State

Zip Code

Employer

Work Number

Home Number

Cell Number

Social Security Number

Driver's License Number

Email Address


4. Who May We Thank For Referring You?

Name


5. Who Is Accompanying Your Child Today?

Name *

Relationship *

Do you have legal custody of this child? *


6. Person Responsible for Account

Name *

Relationship

Billing Address

Apt #

City

State

Zip Code

Work Number

Home Number *

Cell Number

Email Address


7. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
/ /

Policy Owner's SSN

Policy Owner's Employer


8. Secondary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
/ /

Policy Owner's SSN

Policy Owner's Employer


9. Dental History

Is this your child's first visit to the dentist? *

If not, how long since the last visit to the dentist?

Previous Dentist's Name

Were any x-rays taken at previous dental visits?

Have there been any injuries to the teeth, face or mouth? *

If yes, please explain:

Why did you bring your child to the dentist today?

Does the child have any of the following habits? *

Lip Sucking / Biting:

Nursing / Bottle Habits:

Nail Biting:

Thumb / Finger Sucking:

Has the child ever had a serious or difficult problem associated with previous dental work? *

If yes, please explain:

Is this child's water fluoridated?

Is the child taking fluoride supplements?

Has the child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?

Does the child brush his/her teeth daily?

Floss his/her teeth daily?


10. Health History

Has the child ever had any of the following conditions? *

Abnormal Bleeding

Allergies to Any Drugs

Any Hospital Stays

Any Operations

Asthma

Cancer


Are the child's immunizations current

Handicaps/Disabilities

Hearing Impairment

Heart Disease/Murmur

Hepatitis

HIV + / AIDS

Kidney/Liver Conditions

Congenital Birth Defects

Convulsions/Epilepsy

Pregnancy

Tuberculosis

ADD/ADHD

Autism Spectrum

Rheumatic/Scarlet Fever

Allergies to Latex Product

Diabetes

Hemophilia/Blood Disorders

Reflux/GI Problems

Sensory Integration

Please discuss any serious medication conditions the child has had: (or write NONE) *

Please list all the drugs the child is currently taking: (or write NONE) *

Please list all drugs the child is allergic to: (or write NONE) *

Child's Physician *

Phone Number

Is this child currently under the care of a physician? *

Please describe the child's current physical health *

11. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You May Refuse to Sign This Acknowledgment

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ('HIPAA'), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  1. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  2. Obtain payment from third-party payers.
  3. Conduct normal healthcare operation such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *
/ /

12. REQUEST FOR CONFIDENTIAL COMMUNICATIONS

Child's Full Name

Date of Birth

I request that all communications to me by ABC Dentistry & Orthodontics and/or the staff be handled as follows:

Written Communications:

Address To

Email Communications:

Address To

Would you like to receive emails?

Oral Communications:

Home #

May we leave a message?


Work #

May we leave a message?


Cell #

May we leave a message?


I prefer to be contacted at

Would you like to receive text messages?

May we leave a message that you need pre-medication?

May we leave a message that you have dental appointment?

OFFICE-USE ONLY

I attempted to obtain the patient's signature in acknowledgment on this Notice of Privacy Practices, but was unable to do so as documented below.

Date
___________________________________

Initials
___________________________________

Reason
___________________________________

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


13. Signature

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *
/ /