Adult_Patient

Date

MonthDayYear
Date
Patient Information
Name

First NameMiddle NameNick Name
Birth Date

MonthDayYear
Date
Age
SS#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
School
Grade
Interests/Hobbies/Sports
How did you hear about our office?
If so Who?
Others, Please List
Patient Information
Mother's Name

Last NameFirst NameMiddle Name
Address(If Different From Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's SS#
Date

MonthDayYear
Date
Home#
Please enter a valid phone number.Format: (000) 000-0000.
Wk#
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Employer
How long at job?
Job Titile
Father's Name

Last NameFirst NameMiddle Name
Address(If Different From Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's SS#
Date

MonthDayYear
Date
Home#
Please enter a valid phone number.Format: (000) 000-0000.
Wk#
Please enter a valid phone number.Format: (000) 000-0000.
Father's Employer
How long at job?
Job Titile
Who is responsibile for making child's appointments?
**For patients with insurance -We will file your claim at no charge and accept assignment of benefits from your primary carrier only. For those who have secondary insurance, we will file your claim and make benefits payable to the insured
Dental Insurance Information
Insured's Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Birth date

MonthDayYear
Date
Insured's SS#
Insured's Employer
Insurance Co. Name
Dental History
Previous Dentist's Name

First NameLast Name
Date of last dental visit

MonthDayYear
Date
Has the child experienced problems with the previous dental work?
If so explain
Has child ever experienced any injury to mouth, teeth or jaw?
If so explain
Has child ever had any pain/tenderness in his/her jaw joint(TMJ/TMD)?
Does the child brush his/her teeth daily?
Floss his/her teeth daily?
Floss his/her teeth daily?
Does/Did child have braces?
Does/ Did child have any of the following habits? (Check boxes that apply to child):
Has your child ever had sealants placed?
On a scale of 1-10 (10 being highest) How important is your child's dental health to you?
Do you think it is important to have your child's teeth cleaned every 6 months?
What is most important about your relationship with Dr. Baluyut?
Medical History
Does child have a personal physician?
Physician's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone#
Please enter a valid phone number.Format: (000) 000-0000.
Date of last visit

MonthDayYear
Date
Please describe child's current physical health
Is child currently under the care of physician?
If yes, what conditions?
Has child ever responded adversely to medical treatment?
Is child taking any medication at this time?

Other
If yes, Please list
Is there anything else we should know about your child's medical history?

Other
If so, Explain
Are child immunizations current?
Does child have or ever had any of the following?(Check boxes that apply to child).
Office Use Only

I reviewed the medical/dental information of this patient named here in
Date

MonthDayYear
Date
Signature
Patient Id#
Office Information
APPOINTMENTS:

Please understand that it is important for you to keep your child’s scheduled dental appointments to maintain optimal dental health. Postponing treatment could compromise the child’s condition resulting in discomfort and additional costs.

The child’s appointment time is set-aside, especially for him/her. We strive to stay on time and ask you to be on time for his/her appointments. We ask that if you have a change in your schedule and wish to change his/her appointment, please contact us 48 hours in advance so that we can schedule
another appointment for him/her as soon as possible and make your time available to another patient waiting for an appointment.

Repeated cancellations or broken appointments without a 48- hour notice could result in a broken appointment charge or no reappointment.

PAYMENT:

We have several payment options available to you. These options are described in length on our Financial Menu. Please ask if you have any questions.

We realize that many families are in a state of change. The policy in our office is the parent who presents with the patient for treatment is responsible for payment.

INSURANCE:

We will file your claim for you at no charge. We will estimate a portion that insurance typically pays with the understanding that your plan could pay more or less. Any difference between our estimate and the amount actually paid is due from the patient. We will inform you of this amount.

BILLING:

We have established a financial menu aimed at trying to keep billing costs to a minimum For patients with balance after insurance, payment is due within 60 days. A 1-½% monthly finance charge will be added to all balances that are 60 days overdue.
Patient Consent & Authorization
I affirm that the above information I have given is correct to the best of my knowledge and will be used for treatment, billing, and processing of insurance claims. I will not hold my dentist or any staff member responsible for any omissions or errors that I may have made in the completion of this form. I understand that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary services that my child may need. I assign the Doctor all insurance benefits. I understand that I am responsible for all costs of dental treatment or any services rendered.
Parent Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Information

Patient Information

Dental Insurance Information

Dental History

Medical History

Office Use Only

Office Information

Patient Consent & Authorization