Dentistry Just for Kids New Patient Form

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *


Street Address *

City *

State *

Zip Code *

Gender *

Child's Age

Child's Birthdate *

Child's Home Number *

2. Parent/Guardian Information

Name *

Cell Phone # *

Marital Status *

Street Address *

City *

State *

Zip Code *

Time at Residence *

Birthdate *

Email Address *

Employer *

Occupation *

Time at Employer *

Work Phone *

3. Parent/Guardian Information


Cell Phone #

Marital Status

Street Address



Zip Code

Time at Residence


Email Address *



Time at Employer

Work Phone

Alternative Contact Name


Phone #

4. Primary Dental Insurance

Subscriber's Name

ID #


Insurance Company Name

Insurance Co. Phone

Group #

Insurance Co. Address

5. Secondary Dental Insurance

Do you have Secondary Dental Insurance

Subscriber's Name

ID #


Insurance Company Name

Insurance Co. Phone

Group #

Insurance Co. Address

Whom May We Thank For Your Referral

To the best of my knowledge, the questions on this form have been accurately answered. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my dentist of any changes in my medical or dental health.

Today's Date *

6. Dental History

If patient is a minor give parent or legal guardian's name *

Have we ever treated any member(s) of your family? If Yes, Please list their names:

Patient Physician

Is your child allergic to any of the following?

Are any of the following conditions present in patient's present or past history? *

Abnormal Bleeding Problems

AIDS or AIDS Related Complex

Allergies {hay-fever, pollen)

Allergies (medications, drugs)

Anemia (including sickle cell)



Bladder Disorder

Blood Disorder


Cerebral Palsy

Premature Delivery

Radiation Therapy

Emotional Problems

Thyroid (High or Low)

Neck Ache / Stiff Neck Muscles



Fainting / Dizziness

Hearing Problems

Heart Murmur

Heart Problems



Kidney Disorders

Learning Disabilities

Liver Disorders

Convulsions or Seizures


Ear, Nose, or Throat Problems

Frequent Headaches

Tonsils Removed

Rheumatic Fever

Is your child presently taking any medication? *

If yes, please explain:

Has your child ever been hospitalized? *

If yes, please explain:

Has your child or any family members had a problem under general anesthesia? *

If yes, please explain:

Has your child ever received a blood transfusion? *

If yes, please explain:

Does your child have any special problems not listed above? *

If yes, please explain:

Last Visit to the Dentist, Date?*
Reason for the Visit? *

Have any teeth (including baby teeth) been extracted by a Dentist? *

Have any permanent teeth ever been injured or loosened by a fall? *

Does the patient have speech problems? *

Does the child have any of the following habits? *

Who brushes your child's teeth and how many times per day? NA for orthodontic patients

Do you have well or city water:

Any current dental problems? *

If yes, please explain:

Any unhappy dental visits? *

If yes, please explain:

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

If yes, please explain:


Dentistry Just for Kids+ TK Orthodontics (DJ4K+TKO) is privileged to provide dental services to our family of patients. We respect your time and make every effort to keep you from waiting. As a result, your appointment time in our office is reserved exclusively for you.

We understand that emergencies arise, just as they do for us; however, when a patient fails an appointment without notice, we cannot use that time to meet the needs of other patients.

Confirm your appointment. DJ4K + TKO will contact you multiple times prior to your appointment by text, email and telephone. You must reply to one of these reminders to confirm your appointment.

Late Arrivals: When we reserve time for you, we require all of that reserved time to provide you the best quality dental treatment. If you arrive more than 15 minutes late, your appointment may be rescheduled in order to meet the needs of those who are on time. If this happens, it will be considered a Missed Appointment and the fees may apply as listed below.

Cancellations/Rescheduled Appointments: If you need to cancel or reschedule your appointment, we require at least a 48 hour notice. This process will give another patient the possibility of utilizing that reserved appointment. Cancellations may not be called into our answering service or via email.

No Show/Missed Appointment: A ''No Show" or Missed Appointment occurs when a patient misses an appointment without cancelling at least 48 hours in advance. The account will be charged a fee of $50.00. If there is a second "No Show", a $100.00 fee will be applied to your account. No future appointments will be scheduled without the payment of the fee. A third "No Show" may result in dismissal from the practice.

Medicaid/Hoosier Healthwise Missed Appointments: All missed appointments will be reported to Medicaid and may result in dismissal from the Practice.


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8. Financial Policy

We are very pleased to welcome you to Dentistry Just for Kids + TK Orthodontics (DJ4K+TKO). Our goal is to provide you with the highest quality dental care in a fun and enjoyable environment. Listed below is our financial policy.

  1. Payment for professional services is due at the time dental services are provided. It is our policy to make every effort to provide financial arrangements with you before treatment begins; however, this is only an estimate. We accept cash, checks, debit cards and most major credit cards. We also have several resources for payment options available to help you begin treatment as soon as possible.
  2. If you have dental insurance, we will be happy to file your claim on your behalf. Please be familiar with your insurance benefits as we will collect the estimated amount insurance is not expected to pay, including all fees considered above insurance company's usual and customary fee schedule. Any remaining balances will be billed to you after the claim is paid. Please understand that we file dental insurance as a courtesy to our patients. Our office will make every reasonable effort to obtain payment from your insurance company but you will be ultimately responsible for all outstanding balances.
  3. Some dental plans do not allow payments to non-providers; the insurance company sends the payments directly to you. We will file your insurance for these companies; however, you may be required to pay in full at time of service.
  4. The responsible party is responsible for any balances whether insurance has paid or not after 30 days. Past due accounts will be notified via statements by mail. If the account remains unpaid, we may employ a collection service to collect payment. If the balance is not paid within 90 days, finance charges will be applied each month until paid. For patients who have been in collection in the past, payment will be due IN FULL at time of service. There is a $30.00 service charge on all returned checks.
  5. The parent or guardian who brings a minor in for their initial visit is the responsible party. This parent or guardian is required to pay for professional services regardless of the provisions in the divorce decree, or who has custody, or who has the insurance. Guardianship paperwork must be provided at the initial visit.


  1. I hereby give permission to DJ4K+TKO to render all necessary dental services and undertake any diagnostic measures to facilitate treatment for the patient listed below. Furthermore, I will be responsible for any fees incurred for dental treatment and authorize the release of any information to my insurance company. I understand that some or all of the dental charges may not be covered by my insurance. I unconditionally agree to be responsible and pay DJ4K + TKO for any and all charges not covered by insurance. I agree that in the event I do not payment the amounts due DJ4K + TKO, my account will be placed in the hands of an attorney for collection proceedings. I will be responsible for all attorney fees, court costs, collection costs, consideration for assignment, litigation expenses, as well as any other incidental expenses incurred by DJ4K+TKO.
  2. I have read and accept the above Financial Policy and Authorization and understand it and agree to the terms set forth regarding payment.



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9. Protected Health Information


I request that the following information of my Protected Health Information or my child's Protected Health Information to be released. (Protected Health Information would include your/child's name, diagnoses, dates of service as described in the Notice of Privacy Practices). Dentistry Just For Kids+ TK Orthodontics may disclose information by telephone or in person to the people listed below. This document does not allow the people listed below to receive medical records.


Phone Number


Patient or parent signature (if patient is not 18 or older)

By signing this form I am acknowledging that Dentistry Just For Kids+ TK Orthodontics abides by the HIPAA regulations.

Acknowledgement Receipt of Notice of Privacy Practices

**You May Refuse to Sign this Acknowledgement**

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