New Patient Form-Pediatric Dentistry & Orthodontics for Children

Welcome to Southwest Pediatric Dentistry & Orthodontics!

Please take a few minutes to fill out this form as completely as you can. We look forward to being a part of your smile journey!
Patient Information

Pediatric Dentistry & Orthodontics
Patient's Name

First NameLast Name
Nickname
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Whom may we thank for referring you to our office?
School Name
Favorite Sports or Hobbies
Responsible Party/Parent/Guardian Information #1
Responsible Party Name

First NameLast Name
Relationship To Patient

Other
Billing Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Drivers License Number
Parent/ Guardian is also:
Marital Status
If Married, name of spouse
Responsible Party/Parent/Guardian Information #2
Responsible Party Name

First NameLast Name
Relationship To Patient

Other
Address * if different from above*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Drivers License Number
Parent/ Guardian is also:
Marital Status
Emergency Contact Name & Relationship
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Do you have dental/orthodontic insurance?

IF CURRENT PATIENT/FAMILY: PLEASE LIST INSURANCE
Primary Insurance Company
Policy Holder Name

First NameLast Name
Policy Holder's Relationship To Patient
Policy Holder's Employer
Policy Holder DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder ID or SSN
Policy Group Number
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have Secondary dental insurance
Secondary Insurance Company
Policy Holder Name

First NameLast Name
Policy Holder's To Patient
Policy Holder DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder ID or SSN
Policy Holder's Employer
Policy Group Number
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental & Orthodontic History

Although dentists and orthodontists primary treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have or nay medications you may be taking, could have an important interrelationship with the care that you are receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Previous Dentist or Practice Name
Date of Most Recent Dental Exam
Date Of Most Recent Dental X-Rays
Does your child routinely see the dentist every
Please explain any dental and/or orthodontic concerns
Does your child brush his/her teeth daily?
Floss Daily?
Please Check All That Apply:
If any of the checked boxes need further explanations, please describe:
Has your child had any previous orthodontic treatment or consultations?
If YES, what was completed, and by whom?
Has any other family member had orthodontics?
What was completed, and by whom?
Were the results acceptable?
Medical History
Is your child allergic to any of the following
Please list any other drug/material that your child is allergic to
Please check if your child has a history of any of the following:
If you answered yes to any of the above, please explain in more detail:
Is your child under the care of a physician for a specific condition not listed above?
Please describe:
Has there been any changes in the patient's general health in the past year?
If you answered yes please explain in more detail:
Is any antibiotic premedication required for your child's dental visits?
Please list the reason
Is your child taking any medications (including bisphosphonates, anti-inflammatories and/or steroids)?
Please list any medication and dosage your child is currently taking:
Is there any current medical treatment, impending surgery, or other treatment that may affect your child's dental treatment?
Please Explain
Has your child been hospitalized in the last 5 years (Illness or Injury)?
Please Explain
Physician's Name, Speciality, Phone Number
For Females Only
Has menstruation begun?
If YES, please list month and year, if known.
HIPAA ACKNOWLEDGMENT
ACKNOWLEDGMENT OF PRIVACY POLICY

As required by the HIPAA Privacy Regulations, all patients (or patient’s personal representative) who receive health care services on or after April 14, 2003 must:
- Receive and review the attached “Notice of Privacy Practices”, and
- Review and sign the “Acknowledgment Form” for our records.
I have been presented with a copy of this provider’s Notice of Privacy Policies below, detailing how my information may be used and disclosed as permitted under federal and state law.

Further, I permit a copy of this authorization to be used in place of the original. Please note that the attached Notice of Privacy Policies is not a consent form that must be read in full by the patient and signed before treatment can be provided; rather, the Notice provides each patient with a summary description of:
- How our office will use and disclose their medical information for legitimate business purposes,and
- How each patient can exercise their rights regarding this medical information. If you have any questions about this notice, please call our office at (303) 978-1104 and ask for our HIPAA compliance administrator.
I understand the contents of the Notice
I request the following restriction(s) concerning my personal medical information.
Please see the link below to obtain a copy of our Notice of Privacy Practices
CONSENT FOR DISCLOSURES TO FRIENDS AND /OR FAMILY MEMBER

I authorize Southwest Pediatric Dentistry & Orthodontics, PC to share my Protected Health Information to be disclosed for purposes of communicating results, findings, treatment decisions and financial issues to the family members and others listed below. This will serve as my electronic signature for the Consent for Disclosure Form (If a power of attorney, please provide a copy of the POA).
Additional Name of Authorized Person/Relationship to Patient
FINANCIAL/INSURANCE AND OFFICE POLICIES
Payment Policy

Full payment is due at time of service. We accept cash, personal checks, Visa, MasterCard, American Express, Discover, and have payment plans available through CareCredit. If you have insurance, we will collect applicable copays/deductibles.

Returned Checks Policy

Returned checks are subject to a $35 return check fee.

Dental Benefits

You are responsible for understanding your dental benefits and have ultimate financial responsibility for your account, regardless of whether your dental insurance benefit covers part of your treatment. We are happy to provide you with an estimate of what we believe your dental benefits will cover based on information provided to us by your benefit provider.

Dental services that require laboratory fabrication (e.g. athletic/night guards, pontics, retainers) require full payment at time of impression.

Retail Products, Sonicare toothbrushes, Clinpro Toothpaste & whitening products are non-returnable and must be paid in full at time of purchase.

Past Due Accounts

Accounts more than 90 days past due may be transferred to a collection agency. Patients shall be responsible for all costs incurred for the collection of past due balances. This includes collection agency fees, attorney fees, and any other costs involved in litigation.
Financial policy agreement
INSURANCE ASSIGNMENT OF BENEFITS AUTHORIZATION

I authorize my insurance to pay my benefits directly to the dentist/office for all services rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I acknowledge that I am financially responsible for all charges, whether or not paid by insurance. This will serve as my electronic signature for Assignment of Benefit.
Appointment policy

We realize that there are often circumstances in which you cannot control and we will try to work with you, so please let us know the reason for cancellation.
- 24-hour Cancellation/No Show policy – We request 24-hour cancellation notice in order to give other patients the opportunity to receive treatment. Please give us as much notice as possible when canceling an appointment.
  - You will be charged $75 for a cancelled scheduled appointment when notice given is less than 24 hours before appointment time or for failing to attend your scheduled appointment without 24-hour cancellation notification.
  - Exceptions will be made for illness and inclement weather.
Late Arrival policy – In the event you arrive late for your appointment, your treatment will end at its scheduled time in order not to keep the next person waiting. Remaining services will be scheduled at another time.
Consent for electronic communication

To serve you better, Southwest Pediatric Dentistry and Orthodontics, PC (SWPDO) sends automated SMS Text Message and email appointment reminders. These reminders do not contain Protected Health Information (PHI). At your request, we can also communicate with you for scheduling appointments, providing PHI to you or an authorized recipient, or for other reasons that may contain your PHI.

By selecting below, I authorize SWPDO to contact me by the means selected to the contact information. By authorizing, I acknowledge that I have read and understand the following:

Message/data rates may apply to messages sent to my cell phone.
- I may opt-out of receiving these communications at any time by calling SWPDO at (303) 978-1104 or replying to the text or email as indicated in the message.
- As a general practice SWPDO does not send PHI by email, unless requested by the patient or authorized person to be sent by email.
- If I request anything containing my PHI to be sent electronically, I understand that PHI could possibly be read by unintended parties such as but not limited to the following: people that have access to my devices that receive my email, my email provider, my company (if using company email), stored on servers that are not HIPAA security compliant, etc.
Consent for SMS Text Messaging and Email
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge and it will be held in the strictest of confidence. I understand that this information will be used by the treating provider to help determine appropriate and helpful dental or orthodontic treatment. I also understand that if there is any change to my, or the above-named patient's dental or medical status, it is my responsibility to inform the doctor. I authorize the dental staff to perform any necessary dental services that the patient may need during diagnosis and treatment with my informed consent. The parent and or guardian who accompanies the patient is responsible for payment at time of service unless prior arrangements have been provided. I understand that I am responsible for any amount not covered by insurance; including cost of collections, attorney, and court fees. I also understand by signing below, I hereby acknowledge that I have read, understood, and agree to abide by our Appointment Policy as described above and that I understand I may obtain a copy of our Notice of Privacy Practices at our office.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IF PATIENT IS A MINOR

Form signed byRelationship to Patient
Should be Empty:

Welcome to Southwest Pediatric Dentistry & Orthodontics!

Patient Information

Responsible Party/Parent/Guardian Information #1

Responsible Party/Parent/Guardian Information #2

Insurance Information

Dental & Orthodontic History

Medical History

For Females Only

HIPAA ACKNOWLEDGMENT

FINANCIAL/INSURANCE AND OFFICE POLICIES