Pediatric New Patient HIPAA English

Child Information

All information is CONFIDENTIAL. Fields marked with a * are required
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Child's SS# / SIN
Patient #
Child's Name

First NameMiddle NameLast Name
Child's nickname
Child's gender
Child's Birthdate

MonthDayYear
Age
Child's Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Format: (000) 000-0000.

Responsible Party
Name of the person responsible for child's account
Relationship to patient
Birthdate

MonthDayYear
Responsible party address

Street Address

Street Address Line 2

CityState

Zip Code
Email address
Phone
Format: (000) 000-0000.
SS# / SIN
Driver License #
Who is responsible for making appointments?
Name of person responsible for appointments

First NameMiddle NameLast Name
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
Extension #
Best day to call
Best time of the day to call

Mother Information
Please select relationship
Name

First NameMiddle NameLast Name
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
Ext.
Email
Employer
Occupation
SS#/SIN
Driver License #
Marital status

Father Information
Please select relationship
Name

First NameMiddle NameLast Name
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
Ext.
Email
Employer
Occupation
SS#/SIN
Driver License #
Marital status

Insurance Information
Name of insured
Relationship to patient
Birthdate

MonthDayYear
SS# / SIN
Name of employer
Date employed
Occupation
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance company
Employee #
Group #
Policy/ID #
Insurance Co. address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Deductible
Copay
Amount already used
Max. annual benefit
Do you have any additional dental insurance?

Additional Insurance
Name of insured
Relationship to patient
Birthdate

MonthDayYear
SS# / SIN
Name of employer
Date employed
Occupation
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance company
Employee #
Group #
Policy/ID #
Insurance co. address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Deductible
Copay
Amount already used
Max. annual benefit

Financial Arrangements
For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full is due at each appointment.

Authorization and Release
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services my child may need.
I also authorize the Dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the Dentist or Dentist's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of patient (or parent/guardian if minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Financial Policy
We at Dental Arts are proud to be part of a team whose primary mission is to deliver the finest and most comprehensive health care available today. Your clear understanding of our Financial Policy is important to our professional relationship.
- New Patient must fill out patient information forms prior to seeing the doctor.
- We will request to photocopy your Insurance card (s) and Driver’s License for your record.
- Co-payments and annual deductibles must be collected the same day services are rendered.
- If your insurance company rejects or deny your claim for services rendered, it is your responsibility to pay the remaining balance.
- We reserve the right to charge a fee of $25.00 for last minute cancellations or no show appointment.
Payment options

In addition, we are also dedicated to making top-quality care as cost-effective as possible. To assist you with your healthcare investment, we provide the following payment options:
1. Cash --- includes personal checks.
2. Visa/MasterCard/Amex/Discover --- we accept credit cards as payment for treatment.
3. Care Credit--- the financing plan we offer as a separate line of credit to cover your and your family members’ healthcare needs. With CareCredit :* you enjoy these benefits:
  - Flexible financing options
  - Credit decision usually only takes a few minutes
  - No annual fees or prepayment penalties
We are happy to provide you the above options to allow you to make convenient, low monthly payments. If CareCredit is your preferred option, you can begin any necessary treatment immediately and spread the payments out over time*.

We are pleased you have chosen to become a member of our patient family.

*Subject to credit approval.
Responsible party signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Acknowledgment of Receipt of Privacy Practices Notice
I, Patient name acknowledge that I have received a Notice of Privacy Practices from the above named practice. (Refer to Privacy Policy page)
If a personal representative signs this authorization on behalf of the individual, complete the following:
Personal representative's name
Relationship to individual
Describe your good faith effort to obtain the individual’s signature on this form:
Describe the reason why the individual would not sign this form:
I attest that the above information is correct. Patient or Legal Guardian Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Rows	YES	NO
Is your child's water fluoridated?
Does your child take fluoride supplements?
Does your child suck thumb/finger?
Suck/Bite lip?
Bite/Chew nails?
Chew hard objects (pencils, etc.)?
Grind teeth?
Clench jaws?

Rows	Yes	No
1. Does your child have or is suspected of having any medical, emotional, or behavioral condition?
2. Does the child need to take any medications?
3. Does the child have any allergies for any medications?
4. Does the child have any food or seasonal allergies?
5. Has the child been born permaturely?
6. Has the child had any surgeries in the past?
7. Have you ever been told that the child has a HEART MURMUR?
8. If your child has a Heart Murmur, do they require a prophylactic antibiotic before a dental treatment?

Rows	Yes	No
AIDS/HIV positive
Autism
Anxiety / Depression
Anemia
Arthritis / Joint problem
Artificial heart valves
Asthma
Bleeding disorder / Hemophilia
Diabetes
Faining episodes
Heart murmur / MVP
Heart problems
High blood pressure
History of surgery
History of general anesthesia
Kidney problems
Learning disorders
Neurological problems
Possibility of pregnancy
Rheumatic fever
Seizures / epilepsy
Sickle cell disease
Thyroid problems
Urinary tract disorders

Child Information

Responsible Party

Who is responsible for making appointments?

Mother Information

Father Information

Insurance Information

Additional Insurance

Financial Arrangements

Patient Medical History

Authorization and Release

Financial Policy

Payment options

Acknowledgment of Receipt of Privacy Practices Notice