Child Patient Information Forms

YOUR INFORMATION:

Today's Date:

Full Name:

I prefer to be called:

Gender:

M F

Birthdate:

Age:

SSN# (if billing insurance):

Home Address:

Mailing Address (If different than above):

Home Phone#:

Cell#:

Work#:

PARENT/ GUARDIAN/ RESPONSIBLE PARTY:

Name:

Birthdate:

SSN#:

Address (If different than above):

Employer:

Occupation:

Number of years employed:

Home Phone#:

Cell#:

Work#:

Email Address:

**Whom may we thank for referring you?

DENTAL INSURANCE INFORMATION (PRIMARY INSURANCE)

Insurance Company Name:

Phone#:

Insurance Co. Mailing Address:

Insured's Name:

Relationship to patient:

Date of Birth:

SSN:

Insured's Employer:

Employer's Phone#:

ID#:

Group#:

DENTAL INSURANCE INFORMATION (SECONDARY INSURANCE)

Insurance Company Name:

Phone#:

Insurance Co. Mailing Address:

Insured's Name:

Relationship to patient:

Date:

SSN:

Insured's Employer:

Employer's Phone#:

ID#:

Group#:

DENTAL HISTORY

Why have you come to the dentist today?

Have you experienced problems with dental work?

Yes No

If yes, please explain:

Are you happy with the way your smile looks?

Yes No

If not, what would you want to change?

Are any of your teeth sensitive to hot, cold, or anything else? (explain)

PLEASE CHECK THE FOLLOWING THAT APPLY

Jaw joint pain

Apprehensive about dental treatment

Grind or Clench teeth

Gums bleed, feel tender or are irritated

Periodontal Disease

Dry Mouth

Prev. Ortho

DO YOU REQUIRE DENTAL ANTIBIOTICS PRIOR TO DENTAL PROCEDURES? (if yes, please list directions of what you take):

Previous Dentist :

Date of Last Visit:

City & State

Add new row

MEDICAL HISTORY

Physician's Name:

Address:

Phone#:

Are you currently under the care of a physician?

Yes No

If yes, please explain:

Do you smoke or use tabacco in any form?

Yes No

Are you currently pregnant or nursing?

Yes No

If yes, please specify:

ALLERGIES

PLEASE LIST ANYTHING THAT YOU ARE ALLERGIC TO:

MEDICATIONS-attach list or note below

PLEASE LIST ALL THE MEDICATIONS MEDICATIONS-attach list or note below THAT YOU ARE TAKING (Prescription and over-the-counter **for prescription RX's please note what health problem they're taken for):

Please upload attachment if there are any:

Add file

Please upload a file

If Cancer is selected, please list the type:

If Stroke is selected, please list the date below:

If Hospitalized is selected, please list reasons below:

Please list serious medical conditions and dates they happened:

AUTHORIZATIONS

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.

*I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Name:

Date:

*I understand that where appropriate a credit bureau report may be obtained.

Name:

Date:

I am responsible for payment of services rendered as well as co-pays, deductibles or other services that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my submissions, whether manual or electronic.

Name:

Date:

Acknowledgement of Statement of Privacy Receipt of Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Sequim Family Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information, The Statement of Privacy Practices is also posted in the facility.

Sequim Family Dentistry reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

ln addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare information to the person(s) identified below. (l understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse only:

Yes No

Any Member of my immediate family: (Spouse, Children, Children's Spouses)

Yes No

Any Member of my extended family: (Parents, Grandchildren)

Yes No

Other:

Yes No

If yes, please specify:

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 of patient:

Patient's personal representative:

Representative's Telephone Number:

Date field

OFFICE USE ONLY BELOW THIS LINE

Acknowledgement Not Obtained

Provided Prior to Treatment?

Yes No

Date Statement Provided:

Reason for not obtaining patient signature

Needed more time to review Statement of Privacy Practices Wanted to consult another person before signing Physically unable to sign No reason offered Other

If Other is selected, please specify:

Your information will be encrypted.