Pediatric - New Patient Form | Southern Smiles

New Patient Form (Pediatric Dentistry)

We require completion of this form prior to the doctor completing an initial exam.

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Patient Name: First Middle Last

Patient Date of Birth

Preferred Nickname

The patient’s current schooling is

Public

Private

Homeschool

Other

Name of School Patient Attends

Parent 1 Name

Parent 1 DOB

Parent 1 Phone Number

Email Address for Parent 1

Address (Street)

Address (City)

Address (Zipcode)

Address (State)

Parent 2 Name

Parent 2 DOB

Parent 2 Phone Number

Email Address for Parent 2

Address (Street) - If Different From Above

Address (City) - If Different From Above

Address (Zipcode) - If Different From Above

Address (State) - If Different From Above

Is there a custodial agreement that requires mutual consent for treatment?

Yes

Who is financially responsible for the patient?

DENTAL INSURANCE

Is your child covered by dental insurance?

Yes

Select all that apply to your child’s insurance:

No dental insurance

Covered by traditional dental insurance policy

Child is also covered by a secondary insurance policy

Covered by state MEDICAID dental insurance

Covered by state HEALTH CHOICE CHIP dental insurance

Please enter the information for the PRIMARY policy below:

Subscriber Name

Subscriber DOB

Subscriber Address If Different From Patient

Subscriber ID

Subscriber SSN

Group #

Insurance Company

Provider Phone #

Employer

If you are not sure about the above information, you may email a photograph of the front and back
of the insurance card to info@carypediatricdentist.com. In the event there is secondary insurance,
we ask that you email us that information in advance as well.
In the subject line please write: INSURANCE / PATIENT NAME / DOB.

DENTAL & ORAL HEALTH HISTORY

Do you have any other children who are our patients in our practice?

Yes

Name of Patient’s Previous Dentist

Location of Previous Dentist

What kind toothpaste is your child using?

If yes to one or more of the above questions, please provide details

Is there a history of trauma to permanent adult teeth? (If yes please provide details).

Has the patient experienced injury to the face or jaws? (If yes please provide details).

Does the patient have anxiety about dental appointment appointments? (If yes please provide details).

Are antibiotics required prior to invasive dental procedures? (If yes please provide details).

Please describe any concerns you have about your child’s teeth:

MEDICAL, HEALTH & DEVELOPMENTAL HISTORY

Name of your child’s pediatrician

Approximate date of of last regular medical doctor checkup

Is your child generally in good health?

Yes

Have you ever been told by a physician your child needs to have Prophylactic Antibiotics prior to dental treatments?

Yes

Please List All Medications (Prescription, Over The Counter, Vitamins or Supplements), dosages and dates started to the best of your knowledge. Write “none” if this is the case.

Has your child ever been seriously ill? (If yes please provide details).

Has your child ever been hospitalized? (If yes please provide details).

Has your child ever had any surgeries or operations? (If yes please provide details).

Was your child born prematurely or were there any difficulties at birth? (If yes please provide details).

Please list any other allergies we should be aware of

Please select Yes or No regarding the following conditions as they pertain to the patient:

Note: This section and each condition require a response. Incomplete forms will result in a request to fill out the medical history portion of this form in person.

Vision Impairment

Tuberculosis

Stroke

Spina Bifida

Speech Delay

Snoring

Seizures / Epilepsy

Rheumatic Fever

Pneumonia

Mental Developmental Delay

Mental Health Care

Liver Disease

Hormone/Endocrine Disorders

Kidney Disease

High Blood Pressure

Hepatitis

Physical Developmental Delay

Heart Complications

Hearing Impairment

Headaches/Migraines

GERD or Acid Reflux

Endocrine Disorder

Dizziness Vertigo Fainting

Diabetes / Hyperglycemia / Hypoglycemia

Developmental Disorder/Learning Problems

Depression

Cystic Fibrosis

Congenital Birth Defects

Cleft lip/Palate

Cerebral Palsy

Cancer

Bleeding Disorder

Bladder/Kidney Problems

Bipolar

Autoimmune disorder

Autism/Autistic Spectrum

5 Asthma/Reactive Airway Disease

Arthritis/Scoliosis

4 Anemia/Sickle Cell Disease/Blood

3 Abnormal Bleeding/Bruising

2 AIDS/HIV

ADD or ADHD

Any additional medical history comments:

Who may we thank for referring you to our practice? Check all that apply:

Is there someone specific we may send a thank you to?

Optional: You may upload images such as X-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.

Upload Images

Upload Files

REVIEW & ACKNOWLEDGEMENT OF PRACTICE POLICIES

Thank you for choosing our team for your child’s dental and oral health care. We are dedicated to providing your family with the highest quality of care, using state-of-the-art treatment in a comfortable and professional environment. Please familiarize yourself with the policies of this office. This digital form must be read and signed before treatment is rendered. Please ask questions if you do not understand any of these policies. APPOINTMENTS In order to provide quality, effective care, we utilize an appointment schedule. We aim to give your child all the time and attention required during that appointment time. However, if you are more than 15 minutes late for your child’s appointment, we may need to reschedule to allow enough time for your child’s treatment. We are available when emergencies arise and will do our best to give prompt consideration as needed. CANCELLATION POLICY To cancel your appointment, please notify our office at least twenty-four (24) hours in advance of your scheduled appointment time. Appointment changes can only be accepted during regular office hours. You may be charged a fee for not providing a twenty-four (24) hour notice of cancellation or failing to show up for the appointment. The fee will vary depending on the amount of time scheduled and will not be less than $50.00. If there are two (2) or more missed appointments we may no longer be willing to schedule your child for future appointments. MEDICAID INSURANCE COVERAGE For patients with medicaid insurance, a copy of your child’s valid active medicaid card must be presented at the beginning of the appointment when you check in with our staff. In the event you do not have your child’s card present, the appointment will be rescheduled. POLICY REGARDING PARENTS / GUARDIANS, BEHAVIOR MANAGEMENT & TREATMENT Regardless of disability, treatment needs, or behavior management challenges, it is our goal for every child and parent to have a successful, positive visit in our office. Generally speaking, parents and guardians are welcome to accompany their children into the clinic and be present during the appointment. Some children experience anxiety associated with their dental visits. This anxiety can result in crying, uncooperative behavior, and uncontrolled movements of the head and limbs. This is a common occurrence in a children’s dental practice. When this kind of situation arises, we will be sure that either the parent or the guardian is updated on the behavioral challenge. Some children will show significant improvement in behavior if the parent or guardian is not present. In this case, we may ask you to consider waiting in the reception area. For other children the opposite may be true and we may ask for you to be present to help soothe the child. In some instances, gentle restraint of your child’s movement may be necessary. We will, with your consent and help, gently restrain your child so that we can safely accomplish the examination or the treatment. Restraint may include holding the hands, the legs, and the head. We may also need to use a mouth prop to help your child hold his or her mouth open. We will use the above restraint methods sparingly, only with your consent, in your presence and with your assistance. It is understood that if you do not approve of any restraint that we need to use to complete treatment, we expect you to tell us and we will stop immediately. There are alternative in-office means of controlling behavior that can be utilized. These alternative means include the following: in office nitrous oxide (laughing gas), in-office sedative medications administered prior to the appointment, and possibly in office IV sedation (this option may not always be available in our practice, please inquire). Out of office alternatives include general anesthesia in the hospital setting or referral elsewhere. If you have any questions about the risks associated any of the above approaches, please discuss with our doctor(s). DENTAL INSURANCE POLICIES As a courtesy to our patients we will file the primary dental insurance for your child’s dental care. However, both ADA policy and state COB laws provide that when an insurance company accepts premiums from an employer and the secondary carrier, it should coordinate benefits with the primary carrier and pay its appropriate amount as follows: 1) The coverage from those plans should be coordinated such that the patient receives the maximum allowable benefit from each plan. 2) The aggregate benefit should be more than that offered by any of the plans individually, but not such that the patient receives more than the total charges for the dental services received. Therefore, if there is an overpayment on your claim from your secondary insurance, the additional funds will need to be returned to your secondary insurance company. This is required by the National Association of Dental Plans (NADP), and the American Dental Association (ADA). DETERMINING PRIMARY AND SECONDARY INSURANCE The plan covering the patient, other than as a dependent, is the primary plan. When both plans cover the patient as a dependent child, the plan of the parent whose birthday occurs first in a calendar year should be considered primary. When a determination cannot be made in accordance with the above, the plan that has covered the patient for a longer time should be considered primary. We provide this information to help patients understand the primary and secondary dental policies. Should you have additional questions, we recommend you contact your dental insurance provider or review the American Dental Association website at www.ada.org. The digital signature at the conclusion of this form does hereby convey that I understand that our practice follows ADA and state guidelines for primary and secondary insurance policies. FINANCIAL AGREEMENT & PAYMENT I understand and agree that payment is due on the day services are provided. I understand that my insurance policy is a contract between myself and the insurance company, and our practice is not a party to that contract. I understand that services may not be covered at 100% and not all services may be covered by my insurance policy. While we will assist in determining covered services, our practice is not responsible for unpaid services. I understand that it is my responsibility to know what benefits are provided by my insurance company. I am responsible for informing the office of all changes to my information and insurance prior to my appointments. I understand the practice, or the providers associated with the practice, are considered out of network with all insurance companies. I authorize this practice to release medical information to my insurance company, its agents, or any third party for use in determining my benefits. SPECIAL PROVISION FOR PATIENTS COVERED BY MEDICAID INSURANCE The digital signature at the conclusion of this form does hereby assign all insurance benefits for services rendered directly to our practice from Medicaid or my primary private insurance. FOR ALL PATIENTS: If my account enters a delinquent status, I agree to pay all costs of collections including attorney fees and court fees, if applicable. If my account enters court collection status, I accept that I will no longer be a patient of record. Balances over 30 days may be subject to a 2% late payment fee per month. I understand that the fee for a returned check is $35. Our practice will maintain patient records for a minimum of seven (7) years following the latest date of service, barring any exceptions where required extended retention may be required. RADIOLOGY POLICIES & CONSENT Radiographs / “Dental X-Rays” allow the dentist to diagnose and treat conditions that cannot be detected during a clinical examination. A dental x-ray detects much more than tooth decay or cavities. For example, x-rays may be needed to survey erupting teeth, diagnose bone disease, evaluate the results of an injury, detect abscess, pathology, cancer or plan various dental treatments. If dental problems are found and treated early, before they become visible or painful, dental care is much more comfortable and affordable. Dental x-rays are often a part of a comprehensive oral examination. However, your dental insurance may not cover the fee for every x-ray recommended.

RADIOGRAPH / X-RAY ACKNOWLEDGMENT & PERMISSIONS

Radiograph / X-Ray Acknowledgment & Permissions Radiographs (X-Rays) are likely to be recommended at your child’s dental exam. Please read both statements below and select an answer option:

Statement # 1: In the event that new dental X-rays are recommended by the doctor, I understand that I will be notified in advance prior to any X-rays being taken. I understand that not all X-rays may be covered by my dental insurance. I understand that I am responsible for all fees if my insurance company does not cover all or a portion of the X-rays.

Statement # 2: I DO NOT grant permission for dental X-rays to be taken at the initial exam and I will discuss my concerns with the doctor. I understand that there are numerous dental diseases and pathology that cannot be diagnosed without the use of dental X-rays. I hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral or systemic health conditions possibly present that are not fully diagnosed or remain undiagnosed as a result of opting out of dental radiographs.

I have read statement 1 & 2 and grant permission for X-rays.

I have read statement 1 & 2 and DO NOT grant permission for X-rays.

RELEASE FORM FOR MEDIA USE

We are passionate about creating a lifetime of healthy teeth and beautiful smiles. One of the best
ways to share our enthusiasm and educate people is to share images of our team having fun with
patients in the office and to share our work. We want to create positive and reassuring examples of
good oral health within the community. We often do this by sharing content we have created in: the
office, on our website and social media. Images / video of patients may be a part of that media. We
treat the privilege of sharing our work with great respect.

Please select all of your preferences / permissions that apply below:

I hereby grant permission to use patient images and media obtained as described above to promote the practice and to promote good oral health within the community.

I also grant permission for our family to be ‘tagged’ on social media in conjunction with our posts.

I DO NOT grant permission to use patient images and media obtained as described above.

Please understand that you have the right to revoke permission or grant permission in the future as
you see fit.

CONSENT TO RELEASE RECORDS & CORRESPOND WITH OTHER DOCTORS:
The digital signature at the conclusion of this form does hereby grant and convey permission to:

Request release of records from the patient’s previous dentist as necessary.
Release records to and correspond with specialists for procedures and referrals related to the patient’s recommended treatment plan and oral health.

PRIVACY DISCLOSURE STATEMENT & ACKNOWLEDGEMENT:
This section is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. It discloses to you how we normally operate and
your acknowledgment thereof.

The digital signature at the conclusion of this form does hereby signify that the undersigned does hereby attest to having been made aware that our practice has a written privacy policy, and that a copy of the full privacy disclosure statement regarding HIPPA is available on our website and in office for review.

AUTHORIZATION & DIGITAL SIGNATURE:

The undersigned does hereby attest to:

Having read, understood, and completed this registration packet accurately.
Understands and agrees to abide by the policies herein.
Grants or denies permissions as selected herein.
Furthermore, the undersigned is responsible for informing our practice of any changes to the patient’s contact information, changes in insurance and changes to medical status/history.
Having the authority to sign below.

Your Signature

Date of Signature

McNutt & Associates I DDS, P.A.
DBA Southern Smiles