Dr. Dina Lunken Welcome Form

WELCOME TO OUR PRACTICE!!

Dr. Lunken and her staff are pleased to welcome you and your child/children to our office. To enable us to provide you with the best service possible, please take a moment to fill out the following form. If you should have any questions, please let us know so that we can assist you.

We look forward to working with you in the maintenance of your child's dental health.
PATIENT INFORMATION
Child's Full Name*
Nickname
Age
Birthdate*

MonthDayYear
Date
Sex:

MaleFemale
Pronoun:
Weight:
School:
Grade
Hobbies
Siblings (Name & Age)
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different)
Financially Responsible Party*
Relationship to Patient
Home Phone
Cell Phone*
Parent #1 Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Wk Phone
Employer*
Occupation
Social Security #
DOB*

MonthDayYear
Date
Parent #2 Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Wk Phone
Employer*
Occupation
Social Security #
DOB:*

MonthDayYear
Date
How did you hear about our office?
INSURANCE INFORMATION
Is patient covered under your plan (Parent #1)?
Carrier Name
Phone Number
Group #
Policy #
Is patient covered under your plan (Parent #2)?
Carrier Name
Phone Number
Group #
Policy#
DENTAL HISTORY
Family Dentist (N/A if not applicable)*
Has your child been seen by a dentist before?

YesNo
Dentists name:
Date

MonthDayYear
Date
What Services were performed?

ExamX-RaysCleaningFlourideFillingsCaps
Has your child complained about dental problems?*

YesNo
Does your child brush his/her teeth daily?*

YesNo
Any injuries to mouth, teeth, or head?*

YesNo
If yes explain:
Is Flouride taken in any form?*

YesNo
Does child floss teeth daily?*

YesNo
Habits:

finger/thumb suckingnail bittingmouth breathingpacifiersleeping with bottle/sippy cup
Any unfavorable dental experiences?
How do you anticipate your child to act in the dental chair?
How do you rate your own fear of the dentist?
MEDICAL HISTORY
Child's Physician*
City/State*
Phone*
Does your child have/had any of the following? Please check the appropriate box that applies.

AIDS/HIVCerebral PalsyFainting Hearing ProblemsDevelopmental DelayAnemiaConvulsionsDoes your child have/had any of the following? Please check the appropriate box that applies.Sinus ProblemsAsthmaDiabetesHeart Problems/murmurLatex AllergiesCancerEpilepsyHepatitisADD/ADHDDowns SyndromeSpeech DelayAutismAnxietyOCDDepressionOther
Explaination:
Is child under the care of a physician now?*

YesNo
Receiving any medication or drugs?*

YesNo
Ever been hospitalized?*

YesNo
Ever had surgery?*

YesNo
Is there excessive bleeding when cut?*

YesNo
If yes please explain:
Medications (N/A if not applicable):*
Allergies (N/A if not applicable):*
EMERGENCY INFOMATION: Name #1*
Relationship*
Phone*
EMERGENCY INFORMATION: Name #2
Relationship
Phone
AUTHORIZATION:
I have reviewed the questionnaire and answered the questions accurately, to the best of my knowledge. I understand that the answers I have provided will be used by the dentist to determine appropriate dental treatment for my child, and I agree to notify the dentist if any change in my child’s health status should occur. I authorize the dental staff to perform the necessary dental services my child may need. I also authorize the dentist to release all information necessary to secure payment of benefits. I authorize my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize use of this signature on all insurance submissions.

The undersigned also agree(s) to pay all collection cost incurred, in an amount not to exceed fifty percent (50%) of the unpaid balance, should any unpaid balance be referred to a collection agency, in addition, should any unpaid balance due be referred to an attorney for litigation, all reasonable attorney fees and court costs shall be paid for by the undersigned as allowed by the court.

I understand that my dental insurance carrier may pay less than the actual bill for services.

Notices and Patient Communications:

You expressly consent to be contacted, by DINA LUNKEN DDS or anyone calling on its behalf, for any and all purposes, at any telephone number, or physical or electronic address you provide or which you may be reached, including any wireless telephone number. You agree that DINA LUNKEN DDS may contact you in anyway including calls or prerecorded or artificial voice or text messages delivered by an automatic telephone dialing system or email messages delivered by an automatic emailing system.

You expressly acknowledge that this consent cannot be revoked without prior agreement and acceptance by us.

You agree to promptly notify us at any time your contact information changes.
Signature of parent/guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

INSURANCE INFORMATION

DENTAL HISTORY

MEDICAL HISTORY