Child New Patient Form

General Information

Child's First Name*

Middle

Last Name*

Nickname

Sex*

Male
Female

DOB*

Social Security #*

Is your child adopted?

Yes
No

Purpose of Visit*

Concerns

Child's Interests

Does your child have any special needs?

Any phobias?

Whom may we thank for referring you to us?*

Website
Phone Book
TV
Family/Friend
Other

If other:

Does the child live with both parents?

Yes
Father Only
Mother Only
Shared Custody
Other

If the child has step-parents, please list their names

Parent #1 Full Name*

Address*

City*

State*

Zip*

Home #

Cell #

Office #

Extension #

Email Address*

DOB

Social Security #

Driver's License #

Occupation

Employer

Company Address

Parent #2 Full Name

Address

City

State

Zip

Home #

Cell #

Office #

Extension #

Email Address

DOB

Social Security #

Driver's License #

Occupation

Employer

Company Address

Who is responsible financially for the child's account?*

Who is the child's legal guardian?*

Insurance Information

Do you have dental insurance coverage for your child?*

Yes
No

Parent #1 Insurance Company

Group #

Human Resources #

Parent #2 Insurance Company

Group #

Human Resources #

Dental History

Is this your child's first dental visit?

Yes
No

If no, what is the date fo the most recent visit?

Previous dentist name

Was your child bottle fed?

Yes
No

If yes, until what age?

Has your child ever had any injuries to his/her teeth, mouth, head, or jaws?

Yes
No

If yes, describe

Does your child brush his/her teeth daily?

Yes
No

How many times?

Does an adult assist with the brushing?

Yes
No

Does your child floss daily?

Yes
No

Does an adult assist with the flossing?

Yes
No

Does your child have an orthodontic appliance (past/present)?

Yes
No

Are there any aesthetic concerns?

Yes
No

If yes, describe

Has your child had any bad dental or medical experiences?

Yes
No

If yes, please explain

Please indicate if your child has any of the following mouth habits:

Finger sucking
Mouth breathing
Thumb sucking
Teeth grinding
Uses a pacifier
Lip sucking
Tongue thrusting

Other:

Health History

Child's Physician

Phone Number

Last Physical

Is your child being treated for any condition presently?

Yes
No

If so, explain

Is your child in good health?

Yes
No

Height

Weight

Immunizations up to date?

Yes
No

Any history of hospitalization or surgery?

Yes
No

Please list hospitalizations and surgeries.

Is your child taking any medications currently (including over the counter)?

Yes
No

Please list current medications.

Please check if your child has an allergic reaction to:

Other allergies:

Has your child had a history of any of the following?*

Other medical history:

Parent's Initials*

Date*

Social Media & Website Consent Form

First of all, thank you! Thank you for selecting Gentle Dentistry. We would love to post your review, picture, and experience here online at www.gentledentistrykzoo.com, within our website. If you would like to take part in recognizing our office online within our patient section, homepage or testimonial on our website, Facebook or Twitter, please sign below. This form states that you freely give consent to take part in our website, and authorize that your first name and only initial of your last name can be publicly displayed within Gentle Dentistry's website. You understand that by signing this form you are agreeing to take part in our online media source(s) and website. You have received a copy of this form to take with you, as well. We, the staff here at Gentle Dentistry, thank you; we are happy to have you as a patient here for all your dental health care needs.

Patient/Guardian Signature

Witness Statement

I confirm that I was present for the verbal and written statement summary presented to the patient mentioned above, as well as the execution of this form. I agree that the information was accurately explained to, and apparently understood by, and that informed consent was freely given by the patient.

Signature of Witness

Written Financial Policy

Thank you for choosing Gentle Dentistry. Our primary mission is to enable our patients to achieve excellence in oral health and freedom from head and neck pain. We will make every effort to provide quality dentistry in a caring and pleasant atmosphere.

Payment Options

Full payment is expected at the time of service. You may choose from:

Cash, check, credit card (Visa, MasterCard, Discover, and American Express), debit card, HSA, FSA
Payment Plans from CareCredit

Insurance

We may accept assignment of insurance benefits providing all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer, and the insurance company. You, the patient, have the ultimate financial responsibility for treatment. If any services are rejected by your insurance carrier, you are responsible for the fees. If we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits from your insurance carrier. Accounts not paid within 30 days are subject to a monthly statement fee and may be recovered through a collection agency.

All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid. The payments have nothing to do with the actual charges. The treatment recommended by our office is never based on what your insurance company will pay but what your dental health needs are; your treatment should not be governed by your insurance contract.

Please take the time to review your insurance contract thoroughly so we may best serve you and help you to receive the maximum benefits toward your dental health. As always, you may feel free to ask any member of our team for clarification on services, billing, and insurance.

Cancellation Policy

We would greatly appreciate a 48-hour notice from any patient (or patient representative) should they need to reschedule or cancel an appointment. We reserve the right to apply a cancellation fee if this policy is not respected.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you need or want.

I have read this policy, understand and agree to it.

Signature:*

Date*

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date*

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

DOCTOR/FACILITIES IN THE FUTURE.

Please print name of Patient*

Please sign for Patient/Guardian of Patient*

Legal Representative/Guardian*

Relationship of Legal Representative/Guardian*

Your comments regarding Acknowledgments or Consents

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA*

First Name Only
Proper Surname

Other:

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name

Relationship

Name

Relationship

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA*

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to my Cell Phone
Email Confirmation
Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA*

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to my Cell Phone
Email Confirmation
Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:*

Phone Message
Text Message
Email
Any of the Above
None of the above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you with this information with your knowledge and consent.

Signature*

CONSENT TO PERFORM DENTISTRY

1. I hereby authorize and direct the dentist(s) of Gentle Dentistry and/or dental auxiliaries of his/her choice to perform upon my child (or legal ward) the following dental treatment or oral surgery procedure(s); Including the use of any necessary advisable local anesthesia, radiographs (x-rays), or diagnostic aids.

Cleanlng of the teeth and the appllcation of topical fluoride.
Application of plastic "sealants" to the grooves of the teeth.
Treatment of diseased or injured teeth with dental restorations (fillings) or crowns (caps).
Replacement of missing teeth with dental prosthesis.
Removal (extraction) of one or more teeth.
Treatment of diseased or Injured oral tissues (hard and/or soft).
Pulp (nerve) treatment on one or more teeth.
The removal (excision) of diseased, inflamed hard and soft tissue tumors or lesions.
The placement of sutures for wound closure.
The placement of splints or appropriate wound dressings.
The repositioning of one or more teeth.
Tooth bleaching.

2. I understand that there are risks involved In the treatment and hereby acknowledge that these risks have been explained to me, that I have had an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.

3. I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor(s). I understand that nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nose piece leaves an Indentation or ring around the nose which disappears shortly after the procedure.

This treatment has been explained to me. Alternate methods of treatment, if any have also been explained to me, as have the advantages, disadvantages and risks of each. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there cannot be a guarantee either expressed or implied, as to the result of the treatment or as to the cure.
I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I, therefore, authorize and request the performance of any additional procedures that are deemed necessary or desirable to my child's oral health and well-being in the professional judgment of the dentists of Gentle Dentistry.

4. I understand and have been Informed that there are possible risks and complications associated with the administration of local anesthesia, nitrous oxide, and drugs. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the Injection site), fainting, lip and cheek biting resulting In ulceration and Infection of the mucosa.

5. I also authorize the doctors to use photographs, radiographs, other diagnostic materials and treatment records for the purposes of teaching, research and scientific.

6. The alternatives to these methods of treatments are:

Do nol pertorm the recommended treatment.
Referral to a specially dentist of pediatrics.

Patient's Name*

Date*

Patient/Guardian Signature*

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Name

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Dentist In Kalamazoo, MI

General Information

Insurance Information

Dental History

Health History

Social Media & Website Consent Form

Witness Statement

Written Financial Policy

Payment Options

Insurance

Cancellation Policy

I have read this policy, understand and agree to it.

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

DOCTOR/FACILITIES IN THE FUTURE.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

CONSENT TO PERFORM DENTISTRY

Emergency Dental Care