New Patient Registration - Child

PATIENT INFORMATION

" * " denotes required field
Gender *  Male   Female

RESPONSIBLE PARTY

Gender*   Male   Female
Who does patient live with? *  Both Parents   Mom   Dad   Guardian (if child lives with Guardian please provide legal documentation)
As Responsible Party do you give permission for New England Smile Staff to discuss treatment, appointments and account/billing information with both parents/guardian?*   Yes   No

APPOINTMENT CONFIRMATIONS AND REMINDERS

Phone:*   Yes   No
Text:*  Yes   No
Email:*   Yes   No

INSURANCE INFORMATION

Does patient have Dental Insurance (NOT MassHealth)? *  Yes   No
Does Patient have MassHealth? *  Yes   No

MEDICAL HISTORY


Yes   No

Yes   No

Yes   No

Yes   No
Has patient ever taken or had the following:
Fosamax* Yes  No
Boniva* Yes  No
Actonel* Yes  No
Bisphosphonates* Yes  No
Chemotherapy* Yes  No
 
HEALTH CONDITIONS
Abnormal Bleeding*  Yes   No
ADD/ADHD *  Yes   No
AIDS/HIV*  Yes   No
Allergies*  Yes   No
Anemia*  Yes   No
Asthma/Breathing disorders*  Yes   No
Autism*  Yes   No
Cancer*  Yes   No
Cold Sores*  Yes   No
Diabetes*  Yes   No
Emotional/Psychological Disorder*  Yes   No
Epilepsy*  Yes   No
Fainting Spells*  Yes   No
Frequent Headaches*  Yes   No
Heart Disorder*  Yes   No
Hepatitis*  Yes   No
Kidney Disease*  Yes   No
Liver Disease*  Yes   No
Rheumatic Fever*  Yes   No
Seizures*  Yes   No
Steroid Therapy*  Yes   No
Speech Problems*  Yes   No
Tuberculosis*  Yes   No
Thyroid Disease*  Yes   No
Other*  Yes   No
Female Patients - Please answer the following:
Is there any chance patient could be pregnant?
Yes   No
Is patient taking Birth Control or Hormones?
Yes   No
ALLERGIES

Yes   No

DENTAL CONDITIONS

 Yes   No Has the patient ever been to the dentist before
 Yes   No Is the patient's water fluoridated
 Yes   No Does the patient take or use a fluoride supplement*
 Yes   No Does the patient use fluoridated toothpaste or mouth rinse*
 Yes   No Is the patient apprehensive about dental/orthodontic treatment
 Yes   No Has the patient had problems with previous dental/orthodontic treatment
 Yes   No Has the patient ever had braces
 Yes   No Does parent/guardian or the patient want more information about braces
 Yes   No If the patient plays sports does he/she wear a mouthguard
 Yes   No Does the patient gag easily
 Yes   No Do the patient's gums bleed easily
 Yes   No Does the patient have teeth sensitive to hot or cold
 Yes   No Does the patient clench or grind their teeth

PERSONAL EVALUATION

Are there any known problems or concerns about the patient's teeth or gums?
Yes   No
Are the patient's teeth crooked or crowded and is that a concern?
Yes   No
Does patient have any spaces between their teeth that are a concern?
Yes   No
 


 

APPOINTMENT CANCELLATIONS

As a courtesy, we make every effort to confirm your appointment one day in advance. However, it should be noted it is your responsibility to keep all appointments. We request a MINIMUM OF 24 HOURS to change or cancel an appointment. A fee may be incurred for all failed or late cancellations. For more than two failed or cancelled appointments you may be placed on same day only appointment basis.

DENTAL INSURANCE

If you have insurance coverage, our staff as a courtesy does their best to determine a proper ESTIMATE for you. Due to the many insurance companies and plans we cannot always predict the actual payments your insurance carrier will make. You are required to make payment of your full estimated responsibility upon services rendered. After payments are received from your insurance carrier, you may be required to make additional payments, have a credit issued to your account for future services or may be eligible for a refund. By signing this form, I hereby authorize and direct payment of dental benefits from my insurance company to New England Smile, LLC.

If you have Masshealth coverage, please be aware if you have a lapse in your coverage, or a procedure is denied, you are responsible for any out of pocket expenses that incur. You are responsible for understanding the benefits provided to you.

AUTHORIZATION AND RELEASE

I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child during the period of such dental care to third party payers and/or health practitioners.

INFORMATION REGARDING FILLINGS

Please be advised we no longer use silver (amalgam) fillings on primary (baby) teeth due to substantial improvement in composite/resin (white) filling materials. These new materials have been found to perform better than amalgam on primary teeth. We may still recommend, on occasion, silver (amalgam) fillings in certain cases for permanent (adult) molars or as a request of the parent.

Please be aware that some insurance plans pay differently on composite restorations and your co-payment may be higher. The balance is the patient’s responsibility.

Please contact your insurance if you have any concerns. If finances are a concern, we can submit a pre-treatment estimate with your insurance company for the treatment recommended. We will be happy to assist you with that request.



 
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status.
 
Date *:
Parent/Guardian Signature *
 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have read/received a copy of this office’s Notice of Privacy Practices.
You can find this office’s Notice of Privacy Practices within the HIPAA Privacy Statement located at the bottom of our main web page.
 
Date *:
Parent/Guardian Signature *
Patient Name:
 

SOCIAL MEDIA CONSENT

We like to show off all the fun and great things that happen at New England Smile. Often times we do this on social media in the form of photographs or videos and include our patients and their families. Please let us know if we have your permission to post any photographs or videos that may include you or your child on various New England Smile social media sites. These may include (but are not limited to) Facebook, Google+, Twitter, and Instagram.
*
I consent to New England Smile social media usage I do not consent to social media usage
 
Date *:
Parent/Guardian Signature *
Patient Name:
 

ELECTRONIC COMMUNICATIONS ENCRYPTION WAIVER


When communicating via electronic media (e.g. email) HIPAA standards require us to utilize encryption technology for your privacy. To keep electronic communications private, we utilize third party encryption methods that typically require a password for viewing. If you prefer to avoid encrypting any emails that may contain private information and opt out of data encryption, please fill out the form below. By opting out of electronic encryption all electronic communications will be sent without password protection.
 
I wish to opt out of electronic encryption * Yes  No
 
Date *:
Parent/Guardian Signature *
Patient Name: