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  • PATIENT INFORMATION

    CHILD/MINOR INFORMATION (CONFIDENTIAL)

  • Welcome!

    Thank you for choosing Wabash Valley Children's Dentistry. It is our goal to provide your child with the best possible dental care. To help us meet all of your possible dental health needs, please fill out this form. If you have any questions, please ask any of our staff.

  • Date
     / /
  • Gender
  • Birth Date
     / /
  • Format: (000) 000-0000.

  • GUARDIAN INFORMATION

  • Birth Date
     / /
  • Format: (000) 000-0000.
  • Birth Date
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • Do you have dental insurance coverage for Minor/Child?
  • Format: (000) 000-0000.

  • MEDICAID/HOOSIER HEALTHWISE INFORMATION

  • Is the minor/child covered by Medicaid/Hoosier Healthwise

  • MEDICAL HISTORY

  • Date of Last Physical
     / /
  • Is the Minor/Child on any medications?
  • Has the Minor/Child ever been hospitalized?
  • If so any surgeries?
  • Does Minor/Child bleed excessively when cut?
  • Has Minor/Child had any history or difficulty with any of the following? If yes, please check.

  • DENTAL INFORMATION

  • Has Minor/Child complained of any dental problems?
  • Does Minor/Child brush daily?
  • Floss Daily?
  • Using flouride?
  • Has Minor/Child had any unpleasant dental experiences?
  • Does Minor/Child have any injuries to the head, mouth, or teeth?
  • Does Minor/Child have any mouth habits (thumb sucking, nail biting, pacifier, sleeping with bottle)?

  • EMERGENCY CONTACT INFORMATION

  • In the case of an emergency, whom should we contact?

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE POLICY

  • Due to the tremendous increase in dental insurance coverage and the varied types of insurance programs, our office will adhere to the following, concerning your insurance program.

    1. Your program and insurance is between you and your insurance company. We will file and assist you in recovering the maximum benefits from your program. Extraordinary time spent and special requests from your company may incur administrative charges in handling your policy.

    2. We will wait 30 days from the date of service for payment. After 30 days, your account will be charged 2% per month on the unpaid balance.

    3. A schedule of your financial responsibility will be given to you. You will know your financial part of each appointment, including deductibles, co-payment and services not covered by your program. These must be paid at each appointment.

    4. All insurance payments must be assigned to our office if we agree to wait on payment. Checks sent to you by your insurance company must be endorsed and sent to our office immediately. Failure to comply with this policy will result in a "Fee-for-Service" policy. You will be responsible for 100% of the cost of the appointment and your insurance company can then reimburse you for the services rendered.

    5. You are responsible for all appointments scheduled for your minor/child. 

     

  • WVCD AUTHORIZATION FOR FAMILY COMMUNICATION

  • I authorize Wabash Valley Children's Dentistry, L.L.C. to release the following information about my minor/child's health care (please initial all that apply):

  • I choose not to authorize any individuals at this time: (Initial)

  • I understand that this authorization is valid until revoked by the patient, or the patient's parent/guardian.

  • Date
     / /
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  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge that I have received a copy of the Notice of privacy Practices of the office of the wabash Valley Children's Dentistry, L.L.C

  • Date
     / /
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  • Should be Empty: