Welcome!

Proper dental hygiene begins at an early age. Please take a few minutes to complete the following information so we can better care for your child's dental needs.

Patient and Family Information

Child's Name

Birthdate

Sex

Male

Female

Home Phone

Home Address

City

State

Zip

School

Grade

Responsible Party

Relationship to Child

Name of Mother/Guardian

Birthdate

Social Security #

Home Phone

Address

City

State

Zip

Employer

Business Phone

Cell Phone

Email *

Name of Father/Guardian

Birthdate

Social Security #

Home Phone

Address

City

State

Zip

Employer

Business Phone

Cell Phone

Email *

Child's Dental History

Former Dentist

Office Phone

Address

City

State

Zip

Date of last dental visit

How often does your child brush?

How often does your child floss?

Please check all that apply to your child:

Thumb/Finger Sucking

Fingernail Biting

Grinding Teeth

Lip or Cheek Biting

Jaw Difficulty: Clicking and/or Pain

Child's Health History

Hepatitis - Type (if checked fill in)

Other

Primary Dental Insurance

Person Responsible for Account

Relationship to Patient

Birthdate

Social Security #

Home Phone

Address

City

State

Zip

Employer

Business Phone

Business Address

Occupation

Insurance Company

Insurance Company Address

Subsriber I.D#

Group #

Additional Insurance

Person Responsible for Account

Relationship to Patient

Birthdate

Social Security #

Home Phone

Address

City

State

Zip

Employer

Business Phone

Business Address

Occupation

Insurance Company

Insurance Company Address

Subsriber I.D#

Group #

Assignment and Release

I hereby authorize payment directly to Merrick Pediatric Dentistry for all insurance benefits otherwise payable to me for service rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Signature
Date

MEDICAL HISTORY QUESTIONNAIRE

Name of Child

Name of Legal Guardian

Date of Birth

Sex

Height

Weight

Name & telephone number of your child’s physician

Date of last physical examination

Pharmacy Information

Is your child in good health?

Yes

Has there been any change in their health within the last year?

Yes

Have they ever been hospitalized or had surgery?

Yes

If yes please explain,

Are they taking any medicine(s) including non-prescription medicine?

Yes

If yes please explain

Are their immunizations up to date?

Yes

Has your child had an allergic reaction to medicine or foods?

Yes

If yes please explain,

I certify that I have read and understand the above Medical History Questionnaire. To the best of my knowledge all of the preceding health history answers I have given are true and correct. I will not hold my dentist, or any other staff, responsible for any omissions that I may have made on the completion of this form.

Relationship to patient

Signature of Responsible Party Date

APPOINTMENT POLICY OF MERRICK PEDIATRIC DENTISTRY

All appointment times are reserved especially for your child. Should you cancel or fail to keep your appointment without notifying us 24 hours in advance, that time is lost and you will be subject to a missed appointment fee of $50.00.

We make every effort to stay on schedule and minimize wait times. If you are running late for your child’s appointment, please contact our office to inform us as soon as possible. Should you be more than 10 minutes late, we may not be able to see your child. However, we will make every effort to accommodate you.

Patient name *
Signature of Parent or guardian *

FINANCIAL POLICIES OF MERRICK PEDIATRIC DENTISTRY

Payment is due in full at time services are rendered (if you do not have dental insurance). If you have dental insurance, we are determined to help you receive your maximum allowable benefits. Please provide our office with a completed dental claim form or proof of insurance and we will assist you by submitting your insurance claims. (Please understand that New York State law stipulates that if you have two insurance policies, both insurances must be utilized).

However, you must realize:

1. Your insurance is a contract between you, your employer, and your insurance company. We are not a party to that contract. Not all services are covered in all insurance contracts. Some insurance companies exclude certain services from their plan. (It is yourresponsibility not our office to understand your insurance guidelines).

2. We cannot render service on the assumption that the charges will be paid for by an insurance company. All charges are your responsibility from the date services are rendered.

3. Please understand that our recommendations follow standard of care, not what your insurance will or will not cover. We are committed to providing you with the best possible care.

4. On the onset of treatment, we will provide you with an “estimate” of your total treatment costs. This is only an estimate, and occasionally additional treatment may arise. We will collect your estimated portion at the time services are rendered, submit to your insurance company and then once insurance payment is received we will adjust your account accordingly. (insurance guidelines state that insurance companies must pay within 30 days, if for any reason your insurance company does not this becomes your responsibility)

We must emphasize that as dental care providers, our relationship is with you and not your insurance company. While filing of you insurance claims is a service that we extend to all of our patients, all charges are your responsibility from the date services are rendered.

I have read all the policies described in this form. I agree to follow terms outlined. I understand and accept my financial responsibility to the office. I understand that this office cannot guarantee my insurance status, and any information given to me is and “estimate”, not a guarantee of actual insurance payment.

Name of patient *

Signature *

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

I have received a copy of this office's Notice of Privacy Practices. You may refuse to sign this acknowledgement.

Patient Name(s)

Parent / Legal Guardian Name

Parent / Legal Guardian Signature *