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Child Patient of Advanced Smiles (13 years and Under)
Please complete and submit this form prior to your child's initial dental appointment.
Section A: PATIENT INFORMATION
About Your Child
FIRST Name *
Your answer
LAST Name *
Your answer
Middle Initial
Your answer
Preferred/Nickname
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Age *
Your answer
Social Security # *
Your answer
Address *
Your answer
City, State *
Your answer
Zip *
Your answer
Email Address *
Your answer
Phone (Home) *
Your answer
Phone (Mobile) *
Your answer
Phone (Work)
Your answer
School *
Your answer
Grade *
Your answer
Whom may we thank for referring you? *
Name of person, office or other source referring you to our practice:
Your answer
Emergency Contact *
Name
Your answer
Emergency Contact Phone # *
Your answer
Who will be Accompanying Child to Dental Appointment and What is their Relationship to the Child? *
Your answer
Section B: RESPONSIBLE PARTY INFORMATION
Person Financially Responsible for Child
FIRST Name *
Your answer
LAST Name *
Your answer
Relationship to Patient *
Your answer
Phone *
Your answer
Address *
Your answer
City, State *
Your answer
Zip *
Your answer
Social Security # *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Section C: MOTHER'S INFORMATION
FIRST & LAST Name *
Your answer
Relationship to patient *
Employer *
Your answer
Phone (Home) *
Your answer
Phone (Mobile) *
Your answer
Social Security #
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Driver's License #
Your answer
Section D: FATHER'S INFORMATION
FIRST & LAST Name *
Your answer
Relationship to patient *
Employer *
Your answer
Phone (Home) *
Your answer
Phone (Mobile) *
Your answer
Social Security #
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Driver's License #
Your answer
Section E: INSURANCE INFORMATION
Is the patient actively insured under a DENTAL INSURANCE PPO PLAN? *
Insurance Carrier
Your answer
Employer
Your answer
Primary Subscriber's FIRST Name
Your answer
Primary Subscriber's LAST Name
Your answer
Primary Subscriber's Date of Birth
MM
/
DD
/
YYYY
Subscriber ID
Your answer
Group
Your answer
Insurance Phone
Your answer
Section F: MEDICAL HISTORY
Is your child under a PHYSICIAN'S care now? *
If YES, what for?
Your answer
PHYSICIAN'S Name
Your answer
Is your child currently taking any medications? *
Medications List
Your answer
Primary care provider's name: *
Your answer
Primary care provider's phone number:
Your answer
Health Conditions/Concerns
Check any of the following which your child had or has at present.
Please list any HOSPITAL stays
Your answer
Please list any OPERATIONS
Your answer
Other Medical Alerts
List any other health conditions/concerns, pertaining to your child, that you would like us to know about.
Your answer
Section G: ALLERGIES
Drug Allergies
Check any of the following that apply to your child.
Section H: DENTAL HISTORY
Child's PREVIOUS DENTIST'S Name, Address, Phone *
Your answer
How LONG SINCE your child has seen a dentist? *
Your answer
Last COMPLETE dental exam with X-RAYS date *
Your answer
Is your child having DENTAL PROBLEMS NOW? *
If YES, What DENTAL PROBLEMS/CONCERNS would you like addressed?
Your answer
Is your child's WATER FLUORIDATED? *
Has your child ever experienced pain/discomfort in JAW JOINT (TMJ/TMD)? *
Does your child have any of the following HABITS?
Has your child ever had a serious/difficult problem associated with any PREVIOUS DENTAL WORK? *
Has your child worn BRACES or had any kind of ORTHODONTICS on his/her teeth? *
Your child's CURRENT DENTAL HEALTH is: *
How many TIMES a day does your child BRUSH? *
Your answer
How many TIMES a WEEK does your child FLOSS? *
Your answer
Section I: HIPAA
Consent to HIPAA *
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION AND CONSENT FORM. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the HIPAA INFORMATION AND CONSENT FORM.
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section J: ASSIGNMENT OF INSURANCE BENEFITS
Consent to Assignment of Insurance Benefits *
I hereby authorize the assignment of insurance benefits to Advanced Smiles. I understand that checking the box and typing my full name below serve as my signature and consent to allow Advanced Smiles to file dental insurance claims on my behalf, therefore receiving payment directly for services rendered and covered by my insurance. (Please check box below even if you are not currently insured. Your consent to assign insurance benefits to Advanced Smiles will be needed if you ever decide to use any kind of benefit program at our office.)
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section K: RELEASE OF INFORMATION
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: *
List names of people that your healthcare information may be released to.
Your answer
Consent to Release of Information *
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and dictated by the preceding RELEASE OF INFORMATION FORM. I understand that this consent shall remain in force from this time forward until terminated by patient in writing. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the Release of Information.
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section L: Comprehensive Authorization Consent
I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my child’s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, in whole or in part by my dental care payer. I attest to the accuracy of the information on this page. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the Comprehensive Authorization Consent. *
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
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