New Patient Form

New Patient Form

Please complete this form before coming to your first appointment. This form is secure and meets all the HIPAA requirements.
Patient & Parent Info
Who is filling out this form?*
Does the patient speak English?*

YesNo
Referred By*
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Gender*

MaleFemale
Phone Number*

Area CodePhone Number
Parent Name*
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*

Area CodePhone Number
Employed By*
Work Phone

Area CodePhone Number
Social Security Number*
Marital Status*

SingleMarriedDivorcedSeparated
Relationship to Patient*

MotherGrandmotherFoster MomOther
Is there a 2nd Parent that needs to be added?

YesNo
2nd Parent Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Employed By
Social Security Number
Marital Status

SingleMarriedDivorcedSeparated
Relationship to Patient

FatherGrandfatherFoster DadOther
Other children who have been or are patients?*

YesNo
If yes, list names
Name and Phone of emergency contact other than parents*
Payment & Dental Insurance Info
Dental Insurance Company
Policyholder Name
Subscriber ID Number
Policy Number
Employer
Do you have a 2nd insurance?

YesNo
Dental Insurance Company
Policyholder Name
Subscriber ID Number
Policy Number
Employer
Do you have a 3rd insurance?

YesNo
Dental Insurance Company
Policyholder Name
Subscriber ID Number
Policy Number
Employer
Medical Info
Pediatrician*
Preferred Pharmacy*
Office Policies
Our office policies are as follows:

1. The parent who requests treatment is responsible for all fees for services rendered.

2. Even though there may be some type of insurance coverage, the family is responsible for
co-payment at time of visit.

I fully understand and agree to the above polices.
Parent's Signature*

Clear
Dental History
Is this the child’s first Dental visit?*

YesNo
Approximate Date of last dental visit
Where was the last dental visit?*

This dental officeOther Dental Office
If other office, where were x-rays taken?*

YesNo
Are you aware of any dental problems from which the child suffers?*

YesNo
If Yes, Please Explain:
Does the child have any of the following habits*

Thumb of finger suckingPacifierNail bitingBottle in BedBottle not in bedNone
If yes on either bottle checkboxes, what age was the child off the bottle?
Medical History
Has the child ever had a blood transfusion?*

YesNo
If yes, when was the approximate date?
Immunization shots up to date?*

YesNo
Has the child ever had surgery or been in the hospital overnight?*

YesNo
If yes, please list the approximate date, the reason, and what hospital
Is the child taking any medication?*

YesNo
If yes, please list:
Does the child have any tubes, shunts, or prosthesis?*

YesNo
Does patient need antibiotics prior to dental treatment?*

YesNo
If yes, please explain:
Has the child ever had radiation therapy?*

YesNo
Any known drug allergies?*

YesNo

Has the child ever been diagnosed with any of the following conditions?*

	Yes	No
AIDS
ADD or ADHD
ASD (Autism Spectrum Disorder)
Allergy to Drugs
Asthma Medications
Behavior Problems
Cancer
Cerebral Palsy
Chicken Pox
Recent Exposure to Chicken Pox
Measles
Diabetes
Epilepsy, Seizures
Hepatitis or liver disease/exposure
Hearing Loss
Kidney Disease
Learning Disability
Pregnancy
Skin Rash
Tuberculosis/Exposure

Has the child ever been diagnosed with any of the following conditions?*

AIDSADD or ADHDASD (Autism Spectrum Disorder)Allergy to DrugsAsthma MedicationsBehavior ProblemsCancerCerebral PalsyChicken PoxRecent Exposure to Chicken PoxMeaslesDiabetesEpilepsy, SeizuresHepatitis or liver disease/exposureHearing LossKidney DiseaseLearning DisabilityPregnancySkin RashTuberculosis/Exposure
Blood Disorders*

NoneAnemiaSickle Cell AnemiaHemophiliaOther
Heart Disease*

NoneMurmurCongenital DefectHistory of rheumatic fever
If any of the above, does the patient require an antibiotic prior to dental treatment?
Intellectual Disability?*

YesNo
If yes, Functional Age Level?
Is there any other medical condition from which the child suffers which is not listed? If yes, please list.
Please list any medications that are being taken with the conditions listed above.
I certify that I have read and understand the above. I acknowledge that my questions, if any about the inquiries set forth have been answered to my satisfaction. I will not hold my dentist, or any other, member of his/her staff responsible for any errors or omissions that I may have made In the completion of this form.
Signature of Parent*

Clear
Today's Date*

MonthDayYear
Missed Appointment Policies
1) 24 hour notice must be given to this office if an appointment needs to be changed or cannot be kept. If we do not receive 24 hour notice it will be considered a missed appointment*

I understand
2) If you cannot call during regular business hours you may leave a message on our answering machine*

I understand
3) There will be a charge of $50 per patient for missing or canceled appointment within 24 hours of the scheduled cleaning appointment. There will be a charge of $65 per patient for a missed or cancelled 30 minute appointment with the doctor and a charge of $75 for a missed or canceled 1 hour appointment with the doctor within 24 hours of the scheduled visit.*

I understand
4) There will be a charge of $100 per patient for a missed dental surgery at Oishei Children’s Hospital. The fee must be paid prior to rescheduling the next dental surgery*

I understand
5) After a second missed or canceled appointment without 24 hour notice the patient may be dismissed from the practice with our discretion*

I understand
By signing below you acknowledge that you have read and understand the above policies:
Payment Agreement & Consent

For the Use of Nitrous Oxide
I understand that the use of nitrous oxide is not a covered benefit through my insurance. I give permission for this to be used on my child, and will pay for this treatment at my own expense by cash, credit, debit or check at any future appointments when it is used.*

I understand
Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
Today's Date*

MonthDayYear
Date
Signature of Parent

Clear
Should be Empty:

New Patient Form

Patient & Parent Info

Payment & Dental Insurance Info

Medical Info

Office Policies

Dental History

Medical History

Missed Appointment Policies

Payment Agreement & Consent

Notice of Privacy Practices