Patient Information Form

Welcome to the office of Dexter Pediatric Dentistry! Thank you for trusting us with your child’s oral health care needs. We strive to provide the highest quality of individualized care in a friendly and approachable environment. Bring on the smiles!

Tell Us About Your Child

Child’s Name:

Today’s Date:

Birthdate:

Child’s Age:

Nickname:

Gender

Male Female

Home Phone:

Home Address:

City

State

Zip Code

Add additional child

General Information

Who is accompanying the child today?

Name:

Relation:

Do you have legal custody of the child?

Yes No

How did you hear about us?

Emergency Contact:

Name:

Phone#:

Address:

City

State

Zip

Parents/Guardian Information

Person responsible for account:

Parent’s/Guardian Status:

Parent/Guardian #1 Name:

DOB:

Address: (if different from child’s):

SS#:

Home#:

Cell#:

Email Address:

Employer:

Occupation:

Parent/Guardian #2 Name:

Address (if different):

SS#:

Home#:

Cell#:

Email Address:

Employer:

Occupation:

Primary Insurance:

Subscriber’s Name (whose name is the insurance under?):

Insurance Company Name:

Subscriber ID:

Group#:

Company Phone:

Company Address:

Add new Insurance

Medical History:

Child’s Name:

If Other selected, Please specify

Please explain any of the above indicated, or any other serious conditions not listed:

Is there anything you would like to discuss with the doctor in private?

Please list all medications your child is taking:

Please list any allergies:

Child’s Physician:

Physician's Phone:

Is your child up to date with immunizations?

Yes No

Add additional medical history for Additional child

Dental History

Is this your child’s first dental visit?

Yes No

If no, who was the previous dentist?

Date of last visit?

Does your child have a toothache or any other immediate concern?

Yes No

Is there a history of trauma to the mouth, teeth, or jaw?

Yes No

Do you anticipate your child having difficulty with dental treatment?

Yes No

If yes, why?

Does your child have any oral habits?

Pacifier

Grinding

Nail biting

Finger/Thumb Sucking

Mouth breathing

Other

If Other selected, please specify

Does your child brush their teeth daily?

Yes No

Floss?

Yes No

Does anyone assist with brushing?

Yes No

Does your child use a fluoridated toothpaste?

Yes No

Any history or current use of fluoride supplements?

Yes No

Does your child drink:

City Water

Well water

Bottled Water

Did/Does your child breastfeed?

Yes No

Until what age?

Bottle feed?

Yes No

Until what age?

Does your child have any dietary restrictions?

Yes No

Add additional dental history for Additional child

Our Agreement With You

Insurance

Your insurance policy is a contract between you and your insurance company. You are expected to understand your policy and contact them with specific questions. If there is a change in your insurance or coverage, it is your responsibility to notify our office in order for us to verify your coverage. You will be responsible for the full fee if insurance cannot be verified for any reason.

As a courtesy, we will file your dental insurance on your behalf and accept assignment of payment. Please note, most plans only cover a portion of the cost of dental care. If for any reason your insurance company does not respond with payment within 45 days after service was rendered, the balance will be considered your responsibility and due and payable in full immediately.

Dexter Pediatric Dentistry recommends preventive care and treatment that is in the best interest of your child’s oral health. We do NOT and CANNOT recommend treatment based on your insurance coverage.

Financial Policy

We will ESTIMATE expenses at or prior to each of your visits to our office; however, please be prepared for any deductible, co-pay, or other expenses in excess of the estimates at the time of service. We gladly accept VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CHECK, Care Credit®, and CASH. We reserve the right to charge a $26.00 returned check fee.

Cancellation

We know your time is valuable and so we do our best to make the most of the time we have with you. We make every effort to schedule appointments at the best time for you and your child. We know situations arise that prevent you from keeping an appointment and we simply ask that you give us a 24 hour advanced notice. This is so that we may offer the appointment to another patient who may be in need of the time. We reserve the right to charge a $35.00 cancellation fee for appointments broken with less than 24 hours notice.

I have received and reviewed the information in this questionnaire and agreement.
My answers on the health questionnaire are accurate to the best of my knowledge and I understand that this information will be used to guide appropriate dental treatment of my child. I will promptly notify Dexter Pediatric Dentistry of any changes in my child’s health
I authorize Dexter Pediatric Dentistry to submit insurance claims on my behalf and direct payment of the dental benefits, otherwise payable to me, directly payable to the billing dentist.
I understand it is my responsibility to review my insurance policy and to understand my specific dental benefits as well as to confirm coverage and eligibility for services.
I agree to abide by the terms of this contract and pay for all deductible, co-pay, or other expenses in excess of the estimates at the time of service.

I understand that my insurance is currently in-network

or out-of-network

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name:

Date:

Printed Name/Signature of person responsible for payment (If different than parent/guardian):

Printed Name/Signature of parent or guardian:

Patient Name(s)

Your information will be encrypted.