Children NP Form

We strive to make each of your child’s visits pleasant and comfortable.
Our goal is to teach your child oral habits, which will help, keep their smile beautiful for their lifetime.

Your child

Child’s name:

Nickname:

Sex:

Male Female

Birthdate:

Social Security No.:

School:

Grade:

Child’s home address:

City:

State:

Zip:

Home Phone:

Mother

If not, please specify:

Stepmother Guardian

Name:

Birthdate:

E-mail:

Home Phone:

Work Phone:

Social Security No.:

Employer:

Occupation:

Father

If not, please specify:

Stepfather Guardian

Name:

Birthdate:

E-mail:

Home Phone:

Work Phone:

Social Security No.:

Employer:

Occupation:

Parent’s Marital Status

Please select:

Single Married Divorced Widow Separated

Who is responsible for making appointments?

Name:

Home Phone:

Work Phone:

Best time to call (time):

(days):

Who is responsible for making payments?

Name:

Relationship

Address:

City:

State:

Zip:

Social Security No.:

Primary Dental Insurance

Insured’s Name:

Relationship:

Birthdate:

Social Security No.:

Employer:

Occupation:

Insurance Company:

Additional Insurance

Name Insured’s:

Relationship:

Birthdate:

Social Security No.:

Employer:

Occupation:

Insurance Company:

Health History Health History

Your child’s overall health as well as any medications, which your child takes, could have an important inter-relationship with the dental care your child receives. Please answer each of the following questions completely.

Health History

Has your child had any difficulty with previous visits?

Yes No

Comments:

Has your child ever had any of the following?

Asthma

Yes No

Cancer/Hepatitis

Yes No

HIV/AIDS

Yes No

Hepatitis (A,B,C,D,E)

Yes No

Diabetes

Yes No

Allergies

Yes No

Rheumatic Fever

Yes No

Congenital Heart Defect

Yes No

Convulsions/Epilepsy

Yes No

Tuberculosis

Yes No

Abnormal bleeding

Yes No

Heart Murmur

Yes No

Please list any/all medical problems that your child has, that are as, that are not listed above:

Child’s Habits

How often does your child brush?

How often does your child floss?

Date of last dental visit:

Previous Dentist:

Child’s Physician:

Phone Number:

Is your child’s water fluoridated?

Yes No

Is your child taking fluoride supplements?

Yes No

Does your child:

Suck thumb/finger

Yes No

Suck/bite lips

Yes No

Bite/chew nails

Yes No

Chew hard objects (Pencils, etc.)

Yes No

Grind teeth

Yes No

Clench jaws

Yes No

Does your child have to be pre-medicated with antibiotics prior to dental appointments?

Yes No

If Yes, please explain:

Please list any/all medications your child is presently taking:

Patient Treatment Consent

I authorize the Dentist or designated staff treating my child to perform such diagnostic aids deemed appropriate to make a thorough diagnosis of my child needs. Upon such diagnosis, I authorized the Dentist to perform all recommended treatment and therapeutic procedures to include administering medications as prescribed by the Dentist and mutually agreed upon by me. I assign all dental insurance benefits to which my child is entitled to the extent permitted under my dental insurance policy(s) to the Dentist. This form also authorized this Practice to submit insurance claim forms and receive payment directly from the insurance carrier with the notation “SIGNATURE ON FILE”. I authorized the Dentist to release treatment records/x-rays or any other information deemed pertinent to the insurance carrier as necessary and/or requested.

I agree to be responsible for payment of all services rendered on my dependent. I agree that any unpaid claims the carrier does not pay or any balance that extends beyond 45 days from the date of treatment might be assessed to a service charge and/or turned over to a collection agency. I am aware that if the account is turned over to a collection agency, I will be responsible to pay 25% collection agency fees and/or $50.00 court costs and attorney fees.

I have read the above conditions of treatment and payment and agree to their content.

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.

Signature of parent/guardian:

Date:

The interested parties may revoke this authorization in writing only. n in writing only. Please note once records are established there is a $35.00 charge for duplication of records including $35.00 charge for duplication of records including x .00 charge for duplication of records including x-rays. A $45.00 Broken appointment fee will be applied for missed or canceled appointments without 48 hours notice.

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