New Patient Dental/Health 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.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Child's Birthdate *

Child's Age

School

Siblings We Treat

Does your child have any special interests that we should be aware of? (Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.)


Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Child's Home Number

Do we have a current Financial/Insurance Form on file for this child that has up-to-date billing and insurance information? *
(If not, please visit our website to complete one prior to your child's visit.)

2. Dental History

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

If no, how long since the last visit to a dentist?

Previous Dentist's Name

Date of Last X-Rays 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 your child have any of the following habits?

Does your child have any current dental issues?


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

If yes, please explain:


Is your child's water fluoridated?

Is your child taking fluoride supplements?

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

Does your child brush his/her teeth daily?

Does your child floss his/her teeth daily?

3. Social History

Child's First Language *

Child's Second Language

4. Health History

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

Is your child up to date on immunizations against childhood disease?


If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.

List all drugs your child is currently taking (or write NONE). *

List all allergies your child currently has (or write NONE). *

Child's Physician *

Phone Number

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

Describe your child's current physical health. *

5. Office Policies:

Missed Appointments:

24 hours notice is required to cancel any appointment

If your child or family misses three appointments your child and family may be dismissed from our office. If you arrive over 15 minutes late to your child’s appointment you may be asked to reschedule as the delay affects not only the dental team, but other patients scheduled after you. You are required to bring the patient’s most current insurance card and guardian’s ID to every appointment.

Financial Responsibility:

  1. All payments and co-payments are due at the time of service.
  2. There is a fee for all returned checks. The fee is currently $35.00, but is subject to change without notice depending upon the charges incurred at the bank.

Payment Options:

  1. Cash and/or checks
  2. Credit Cards – Visa, MasterCard, Discover and American Express.
  3. Care Credit

Dental Insurances:

We accept assignment of dental insurance benefits. However, we require your full deductible and/or co-payments to be made at the time of service. Please keep in mind that we can only estimate your portion. The balance of your account is your responsibility. We will not enter into a dispute with your insurance company over your claim. Please note that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and customary under your insurance plan. It is your responsibility to know your insurance benefits, and disclose them to us.

At this time, our office does not participate with any HMO plans. You may be entitled to reimbursement from the insurance for the services rendered.

If your insurance does not pay within 45 days, you will be held responsible for the full payment. If payment is not received within 90 days your account will be handled by a collection agency.

Hospital:

Parents of children requiring dental treatment in a hospital setting will be required to pay a nonrefundable processing fee of $200.00 depending on the facility chosen for treatment. This is a special service our office provides to check your medical eligibility therefore we require payment in full prior to your scheduled treatment date.

Nitrous Oxide (Happy Air)

This service is used to reduce anxiety that a child may have at the time of visit. This is not a covered service by most insurance companies, but highly recommended by our doctor when performing restorative and surgical procedures in some children.

Parent guidelines:

You may choose whether to remain at your child’s side during his/her restorative appointment. Although we sense that some children do better without parents present, when the parent is anxious. We are open to having you stay with your child. If you choose to be present, we suggest the following guidelines to improve the probability of a positive outcome:

  1. Allow us to prepare your child.
  2. Be supportive of the practices terminology.
  3. Please be a silent observer.
    • This allow us to maintain communication with your child.
    • Children will normally listen to their parents instead of us and may not hear our guidance.
    • You might give incorrect or misleading information.

These are important ways that you can actively help in the success of your child’s visit. We are confident that all will go well and hope these guidelines will help prepare you for your next visit.

Minor Patients:

Parent or legal guardian must accompany a minor patient during all visits. If parent or legal guardian cannot accompany minor a written consent signed by the parent or legal guardian (You can find a form in our website) must be presented to our staff and payment should have been arranged in advance, otherwise our office cannot provide services that day.

Divorce Decree:

Regardless of your divorce, the accompanying adult is responsible for payment. Financial arrangements between parents or guardians must be made in advance. We will not bill to a third party.

Mission Statement:

Our pledge is to provide exceptional care and to treat every child like we would treat our own. We will do our best to present you with all the options we are aware exist to treat your child’s conditions. We want you to feel comfortable with the recommended treatment and encourage you to communicate with us to make an informed decision.

Thank you for understanding our office guidelines and financial policy and for choosing us as your child’s dental home.

6. Signature

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

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

Relationship to Patient *

Date *