Pediatric Dentistry of Hamburg: Georgetown Office New Patient Forms

  • Pediatric Dentistry of Hamburg: Georgetown Office New Patient Forms

    Rodney A. Jackson, DMD | Morgan C. Dillow, DMD | R. Michael Day, DMD | Amy Luley, DMD

  • 208 Bevins Lane, Suite A, Georgetown, KY 40324 | (502) 570-2829


     -----

    Due to limited space and seating in our office, we can only allow 1 parent per child in the clinical area during their appointment. Thank you for your understanding and cooperation!

  • DEMOGRAPHIC INFORMATION

  •  - -
  • Who referred you to us?

  • TREATMENT AUTHORIZATION / FINANCIAL AGREEMENT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Child lives with*
  • Parent's Marital Status*
  •  - -
  •  - -

  • Person to be contacted in an emergency (other than parents).

  • Format: (000) 000-0000.

  • APPOINTMENT & CANCELLATION POLICIES

  • ONE parent is permitted to remain with each child during treatment (other than sedation appointments). Dr. Jackson, Dillow, Day, Luley, or Haggerty will discuss with you the terms and conditions for this privilege. Other guests/siblings must remain in the waiting room accompanied by an adult.

    We request that 24-hour notice be given if you cannot bring your child for their scheduled appointment. You will be charged $25.00 for broken appointments when illness is not a factor and 24-hour notice is not given.

    I have fully read and understand the above APPOINTMENT & CANCELLATION POLICIES and accept all provisions.

  •  - -

  • MEDICAL HISTORY

  • Format: (000) 000-0000.
  • Is Your Child in Good Health?*
  •  - -
  • Are your child's immunizations up to date?*
  • Please check if your child has or has had any of the following:
  • Is today your child's first visit?*
  •  - -
  • Does someone help?*
  • Does your child use a fluoridated toothpaste?*
  • Is your home water fluoridated?*
  • Does your child drink milk/soda/juice between meals?*
  • Does your child eat frequent snacks between meals?*
  • Are there any mouth habits?
  • Do you expect your child to cooperate for the exam?*
  • Does your child work with a speech therapist?*

  • I hereby acknowledge that the information provided above is a true representation of my child's medical and dental history/condition.

  •  - -

  • PHOTO RELEASE

  • Occasionally we use photographs of our patients in advertising, in our office, on our website, or on our Facebook page. Please choose yes to give permission for us to use photos of your child or no to deny permission.*
  •  - -

  • HIPAA

    NOTICE OF PRIVACY PRACTICES

  • The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program requiring all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives, you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

    The following is an explanation of how we are required to maintain the privacy of our health information and how we may use and disclose your health information.

    We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations, and when required by law.

    Treatment means providing coordination or managing health care and related services by one or more health care providers. An example of this would include sending documents to an oral surgeon for a tooth extraction or contacting your pediatrician regarding treatment. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your treatment to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

    We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    You have the following rights with respect to your protected health information, which you may exercise by presenting a written request to our Privacy Officer:

    The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. Thank you for your attention to this matter.

    I understand the above information and agree with its contents, and this will serve as my electronic signature.

  •  - -
  • Should be Empty: