Dr. Skordalakis 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.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Child's Birthdate *

Siblings that we treat

Name of school and grade that your child attends (if any)

Hobbies or special interests (Although this question is optional it will help us communicate with and get to know your child better.)


Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

2. Parent or Legal Guardian's Information

The following information applies to the main legal caregiver for the above named child (where the child lives.)

Parent or Legal Guardian's Name *

Relationship to child *

Birthdate *

Cell Phone *

Home Phone

Email *

Social Security Number *

Employer & Occupation

How did you learn about our office?

3. Spouse or Other Legal Parent or Guardian

Spouse or Other Legal Parent or Guardian's Name

Relationship to child

Birthdate

Cell Phone

Home Phone

Email

Social Security Number

Employer & Occupation

Marital Status *
       

4. Who Will be Accompanying the Child to His / Her Appointment?

Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.

Name *

Relationship to child *

Do you have legal custody of this child? *

5. Responsible Party / Billing Information

Responsible Party's Name *

Relationship to child *

Billing Address (if same as child's address above, you may leave this section blank)

Apt #

City

State

Zip Code

Cell Phone *

Home Phone

6. Dental Insurance Information

Primary Insurance Company's Name

Primary Insurance Company's Address

Insurance Company's Phone

Subscriber ID # *

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to child

Birthdate

Employer

7. Dual Insurance Coverage?

Please complete the following information if you have secondary dental coverage for your child.

Do you have dual (secondary) insurance coverage?

Secondary Insurance Company's Name

Secondary Insurance Company's Address

Insurance Company's Phone

Subscriber ID #

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to child

Birthdate

Employer

8. Child's Health History

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

Please discuss any serious medical conditions your child has had (if none, write "none"): *

List all drugs your child is currently taking and dosage if known (or write NONE). *

List all allergies (or write NONE). *

Child's Physician *

Phone Number

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

Explain.


Are there any other details of your child's health that we should be aware of?

Describe your child's current physical health. *

9. 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

Were any x-rays taken at previous dental visits?


List any injuries to the teeth, face or mouth or write "none", if no prior injuries. *

Why did you bring your child to the dentist today?

If your child has ever had a serious or difficult problem associated with previous dental work, please explain, or write "none" if nothing exists. *


Check any of the habits your child may have.


Is your child currently using or have a history of tobacco use? *


Check any of the following that apply to your child:


10. Office Policies, Patient & Family Responsibilies

Patients with insurance coverage:

As a courtesy, a claim is filed with your dental insurance company using information you provide us. Therefore, you must provide accurate information; a fee is charged for resubmitting a claim when incorrect information is provided. Insurance has limitations, restrictions and partial coverage for most dental services; example: fluoride treatment, sealant, resin/white filling, crown. Without exceptions, payment is required at the time of service for patient portion – deductible, co-pay amounts. Please note that we can only estimate the patient portion – it is not the exact amount you owe. The exact patient portion will be known only after the claim is processed by your insurance, and a statement is then mailed to you for any balance amount.

Patients without insurance coverage:

Treatment plan with estimate of fees is provided prior to starting dental treatment. Without exceptions, full payment is required at the time of service.

Minor patients:

Both parents or guardians are financially responsible for full payment at the time of visit. In the case of divorced or separated parents, both parents are responsible for full payment, without any exceptions.

Payment methods:

Cash, check, debit, and credit cards: MasterCard and Visa, Discover and American Express.

Returned checks:

$40.00 charge applies when a check is returned by the bank due to insufficient funds.

Finance charge:

After a dental claim is processed by insurance, a statement is mailed to the address on record for the remaining balance. Payment is expected within 15 days of the statement date, to avoid 1.5% monthly finance charge.

Refunds:

An account with a credit balance is issued a refund check in the name of the person shown under “Financial Responsibility for account” and mailed to the address on file. You may choose to keep the credit balance in our office for use towards future dental care.

Missed Appointments-24 hour notice needed:

To reschedule an appointment, our office must be notified at least twenty four (24) hours in advance.

Termination of Treatment:

Our office reserves the right to cancel future appointments and terminate professional relationship for any of these reasons:

  • When scheduled appointments are not kept
  • When patient arrives late to scheduled appointments causing inconvenience to other patients
  • Uncollected debt owed (past due account) to this office.

 

American Credit Bureau:

Our accounting department promptly reports past due and delinquent accounts to the national credit bureaus – Equifax, Experian, and Trans Union.

Financial Responsibility Agreement

By signing this document, I understand and agree to the following:

  • I am responsible for payment of all charges for services rendered, regardless of insurance coverage.
  • Unpaid balance for more than 30 days after services are rendered is subject to interest of 18% per annum.
  • Unpaid balance over 60 days is reported to American Credit Bureau. The debt owed to this office will appear on my permanent credit file at the nation’s leading credit bureaus – Equifax, Experian and Trans Union. To collect the debt, such an account may also be sent to an attorney or collections agency and I agree to pay 33.3% attorney’s fees, all court costs and fees associated with the collection efforts.

 

Consent & Authorization

By my signature below, I authorize dental treatment for my child and understand the following:

  • To the best of my knowledge the above information is accurate, and will not hold Dr. Skordalakis, DDS, or his team members responsible for any errors or omissions made while completing this form.
  • Providing incorrect information is dangerous to my child’s health and safety, and it is my responsibility to inform Dr. Skordalakis or his team members when there is a change in my child’s medical condition, or when there is a change in the responses to any of the above questions.

 

11. Acknowledgement Statement of Privacy Practices

I acknowledge that I have received the Statement of Privacy Practices (“Statement”) for the office of Dr. Skordalakis, DDS, PC. The Statement describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. Also, it describes my rights and the responsibilities and duties of the office with respect to my protected health information. The Statement is posted in the facility.

Dr. Skordalakis, DDS, PC reserves the right to change the privacy practices that are described in the Statement. If privacy practices change, I will be offered a copy of the revised Statement at the time of my first visit after the revisions become effective.

12. Additional Disclosure Authority

In addition to the allowable disclosures described at the front desk, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below

Check any of the following that apply to your child:

Other

13. 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 *