Pediatric Dentistry of Winchester: New Patient Forms

Pediatric Dentistry of Winchester: New Patient Forms

Donna Klein, DMD | 2560 Bypass Road #2, Winchester, KY 40391
Child Patient Information
Patient's Name*

First NameMiddle NameLast Name
Patient's Preferred Name
Patient's SSN
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*

MaleFemale
Do we see other children in your family? If so, please list their names.*

NoYes
Who referred you to us?

GoogleSocial MediaFriend (Please List Their Name)
If you were referred to us by another dentist or doctor, please provide their name.
What is the reason for your child's dental visit?*

Parent/Guardian Information
I am the ______.*

ParentGuardian
Is the patient in the custody of the state or foster care? If yes, please list the name and phone number of of social worker.*

NoYes
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Date of Birth*

MonthDayYear
Date
Parent / Guardian Cell*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Someone not living in the household):*

First NameLast Name
Relation:*
Phone Number*
Please enter a valid phone number.

Dental Insurance Information
We need dental insurance information NOT your medical insurance information. They are different.
What kind of dental insurance do you have?*
Which Medicaid insurance carrier do you have?*
Please list your Medicaid ID number.*
***We need your Dental Insurance information NOT your medical insurance information (they are different)***

Please take and attach a picture of your dental insurance card (if available).

Make sure the photo is in focus and not blurry.
FRONT of Medicaid Insurance Card
BACK of Medicaid Insurance Card
Policy Holder's Name*

First NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy Holder's SSN#*
Policy Holder's Employer*
Dental Insurance Carrier*
Dental Insurance Phone Number*
Located on the back of card
ID / Member #*
Group #*
***We need your Dental Insurance information NOT your medical insurance information (they are different)***

Please take and attach a picture of your dental insurance card (if available).

Make sure the photo is in focus and not blurry.
FRONT of Dental Insurance Card
BACK of Dental Insurance Card
Are you covered by a secondary dental insurance plan?

YesNo
Only fill out the following information if you ARE covered by a secondary dental insurance plan.
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's SSN#
Policy Holder's Employer
Dental Insurance Carrier
Dental Insurance Phone Number
Located on the back of card
ID / Member #
Group #

Appointment & Cancellation Policies
ONE parent is permitted to remain with each child during treatment (other than sedation appointments). Dr. Donna will discuss with you the terms and conditions for this privilege. Other guests/siblings must remain in the waiting room accompanied by an adult.

I have fully read and understand the above APPOINTMENT & CANCELLATION POLICIES and accept all provisions.
Parent/Guardian's Signature:*

Clear
Date*

MonthDayYear
Date
Relationship to Patient*

Consent for Non-Guardian
In order to make your visit as prompt and as pleasant as possible, please provide the following information:

As guardian, I hereby give the following person(s) my permission to bring my child/children to Pediatric Dentistry of Winchester.
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Guardian's Full Name

First NameLast Name
Today's Date

MonthDayYear
Date
Guardian's Signature:*

Clear
Photo Permission Agreement
Occasionally we use photographs of our patients in advertising, in our office, on our website, or on our Facebook page.

Do you, , parent or guardian of, , hereby grant permission to Pediatric Dentistry of Winchester to use photographs or video of my child?
YesNo
Parent/Guardian's Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

	Has / Had	Never
Abnormal Bleeding/Hemophilia
Acid Reflux
ADD/ADHD
Anemia
Apraxia/Speech Disorder
Artificial Heart Valve
Asthma/Breathing Problems
Autism/Asperger's/PDD
Blood Transfusion
Cancer
Cerebral Palsy
Cleft Lip/Palate
Cold Sores
Congenital Heart Condition
Depression/Mental Health Disorders
Diabetes
Down Syndrome
Dry Mouth
Eating Disorder
Epilepsy/Seizures/Neurological disorders
Epinephrine Sensitivity
Fetal Alcohol Syndrome
GERD/Acid Reflux
Hearing impairment
Handicaps/Disabilities
Heart Murmur
Hepatitis
High Blood Pressure
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Kidney/Liver Condition
Leukemia
Low Blood Pressure
Lymphoma
Latex Allergy
Metabolic Disorder
Migraines/Headaches
Operations/Hospital Stays
Organ Transplant
Premature Birth
Pre-med for Heart Condition
Radiation Therapy
Rheumatic Fever
Seasonal Allergies
Sleep Apnea
Stroke
TMJ Disorder
Tuberculosis
Ulcers
Vision Problems
Vitamin Deficiency

Pediatric Dentistry of Winchester: New Patient Forms

Parent/Guardian Information

Dental Insurance Information

Appointment & Cancellation Policies

Medical History

Consent for Non-Guardian

Photo Permission Agreement