Child New Patient Form

  • Child New Patient Form

  • Today's Date*
     - -
  • Birth Date*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Insurance Subscriber's DOB*
     - -

  • Dental History

  • To your knowledge do you have any outstanding dental work that needs to be completed?*
  • Do you give permission for our office to share images and consult/treatment notes with their dentist?*
  • Habits
  • Has there been injury to the face, head or neck?*

  • Dental History

  • Chipped or injured primary or permanent teeth?*
  • Jaw fractures, cysts, infections?*
  • History of speech problems or speech therapy?*
  • Difficulty breathing through nose?*
  • Mouth breathing habit or snoring at night?*
  • Frequent oral habits(sucking finger, chewing pen, etc.)?*
  • Teeth causing irritation to lip, cheek or gums?*
  • Abnormal swallowing (tongue thrust)?*
  • Tooth grinding or clenching?*
  • Clicking, locking in jaw joints?*
  • Soreness in jaw muscles or face muscles?*
  • Ringing in ears, difficulty in chewing or opening jaw?*
  • Have you ever been treated for “TMJ” or “TMD” problems?*

  • Medical History

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Is your child under a physician’s care now?*
  • Has your child ever been hospitalized or had a major operation?*
  • Has your child ever had a serious head or neck injury?*
  • Is your child taking any medication pills or drugs?*
  • Is your child allergic to any of the following?
  • Does your child have any of the following?*
  • Have your child ever had any serious illness not listed above?*
  • Date*
     - -

  • Pediatric Sleep Questionnaire

    Questionnaire Used to Identify Sleep Disorder Candidates

  • Dr. Diers would like you to complete the following questionnaire for your child to help him evaluate their current sleep and airway situation which plays a major role in dental development.

    Select the appropriate response:

  • While sleeping, does your child snore more than half the time?*
  • While sleeping, does your child always snore?*
  • While sleeping, does your child snore loudly?*
  • While sleeping, does your child have "heavy" or loud breathing?*
  • While sleeping, does your child have trouble breathing or struggle to breathe?*
  • Have you ever seen your child stop breathing during sleep?*
  • Does your child tend to breathe through their mouth during the day?*
  • Does your child have very dry mouth when waking in the morning?*
  • Does your child occasionally wet the bed?*
  • Does your child wake up un-refreshed in the morning?*
  • Does your child experience sleepiness during the day?*
  • Has a teacher or supervisor commented that your child appears sleepy of sluggish during the day?*
  • Is it hard to wake your child up in the morning?*
  • Does your child ever wake up with headaches?*
  • Did your child ever stop growing at normal rate?*
  • Is your child overweight?*
  • This child does not listen when spoken to directly.*
  • This child often is easily distracted.*
  • This child often has difficulty organizing tasks and activities.*
  • This child fidgets or squirms.*
  • This child is often "on the go" or acts as if "motor driven".*
  • This child often interrupts or intrudes.*

  • Acknowledgement of Receipt of Statement of Privacy Policy

  • I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Nelson R. Diers, D.D.S. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

    Nelson R. Diers, D.D.S. reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

  • ADDITIONAL DISCLOSURE AUTHORITY

    In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

  • Any member of my immediate family*
  • Spouse only*
  • Other (please specify)*
  • Date*
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  • Statement of Privacy Practices

    Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

    Protecting Your Personal Healthcare Information

    We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Account-ability Act and the state of Ohio. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone - even family members - without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

    Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentially of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

    Collecting Protected Health Information

    We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

    Disclosure of Your Protected Health Information

    As stated above, we may disclose information as required by law. We are obligated to provide information to law enforce-ment and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent.

    We may use and/or disclose your health information to communicate reminders about your appointments including voice-mail messages, answering machines, and postcards.

    Patient Rights

    You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stat-ed above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

    We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

     

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