Child New Patient Information

TELL US ABOUT YOURSELF

WHO IS ACCOMPANYING THE CHILD TODAY?

MOTHER'S INFORMATION

FATHER'S INFORMATION

PERSON RESPONSIBLE FOR ACCOUNT

Who is responsible for making appointments?

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and 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.

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.

The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved.

OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the parent / guardian & patient named herein.

Medical History Update

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

have received a copy of this office's Notice of Privacy Practices.

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.

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Prlva·cy Practices, but acknowledgement could not be obtained because:

• Individual refuse to sign
• Communications barriers prohibited obtaining the acknowledgment
• An emergency situation prevented us from obtaining acknowledgment
• Other (Please Specify)

2002 American Dental Association All Rights Reserved

Reproduction and use of this form by dentists and their staff are permitted. Any other use, duplication of this form by any other party requires the written approval of the American Dental Association.

This form is educational only, does not constitute legal advice, and covers only federal, not state, law (Augusta 2014)

APPOINTMENT SCHEDULE ACKNOWLEDGEMENT

Dr. Makerson and her team would like to take the time to thank you for choosing our dental office for your oral health care. It's our goal to provide the best care and service possible to you, your family and friends. This letter is to Inform all of our wonderful patients of the updates with our schedule.

Our team arrives at 8:00 a.m., Monday-Thursday to assist you with appointments or any questions. It is our intention to stay on schedule at all times. Occasionally we may experience interruptions in our schedule due to emergencies or other delays. Please be on time for your appointments. Most procedures require the full amount of scheduled time for treatment. If you are late we may require the appointment to be rescheduled. All of our appointments are scheduled specifically for each patient, therefore a missed appointment hurts you. (the patient), the team, and prospective patients. It is very Important that you keep all scheduled appointments. A $25.00 fee will be charged for all missed appointments. (no shows) and appointment canceled less than 24 hours.

We know that certain circumstances are beyond your control, such as emergencies, and work schedules, sometime arise. however. we wish that you give us a call. NO CALLS, NO SHOWS. WILL BE CHARGED. Repeated cancellations or missed appointments will result in loss of future appointment privileges,

We welcome new patients and are grateful to our patients who have referred their family and friends to our office. Your expression of confidence is greatly appreciated. We look forward to serving you in years to come and thank you in advance for your cooperation.

Thank You,
Makerson Dental Team

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.