Kentuckiana Pediatric Dentistry Patient Form

Kentuckiana Pediatric Dentistry
NEW PATIENT INFORMATION FORM
Please read this form carefully! If you do not understand something to your satisfaction, please ask questions. We will be pleased to explain it :)

1. I request and authorize the dental treatment and associated procedures for:
Patient Name:*
Today's Date:*

MonthDayYear
Date
2. I understand that treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Behavior will be guided using praise, explanation and demonstration of procedures and instruments, using variable voice tone and loudness.

3. I further request and authorize the taking of oral dental x-rays and the use of such anesthetics as may be considered necessary to treat the patient's dental problem(s).

4. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided. During such disruptive behavior, it may be necessary for the assistant(s) to hold the patient's hands, stabilize the head and/or control leg movements.

5. For the purpose of advancing medical-dental education, I give permission for the use of clinical photographs of the patient for diagnostic, scientific, education or research purposes.
Parent/Guardian Initials:*
6. I have had explained to me by Dr. Mitchel and their associates, and have had sufficient opportunity to discuss the patient's dental condition/problem(s), the planned procedures and treatment, and the benefits, to be reasonably expected from this treatment plan, compared with alternative approaches and/or no treatment.

7. The usual and most frequent risks or complications occurring from the planned treatment and procedures also have been explained to me. These risks include, but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury to adjacent teeth, and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions.

8. I understand that during the course of the patient's dental treatment, something unexpected may arise that may necessitate procedures in addition to or different from those listed on the patient's PLAN OF CARE and that I will be consulted prior to initiation of treatment procedures not listed. I am aware that the practice of dentistry is not an exact science and acknowledge that no guarantees have been made to me concerning the results of the dental treatment that the patient receives in the office.

9. All of my questions have been answered to my satisfaction and I consent to the treatment and procedures prescribed for the patient on the PLAN OF CARE.

10. I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated.

11. I request and authorize the dental treatment and associated procedures outlined on the PLAN OF CARE.

12. I confirm that I have read and understand this form or it was read to me, and that all blanks were filled in and all applicable paragraphs, if any, were stricken before I signed below.
Digital Signature of Person Consenting to Treatment:*

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Date:*

MonthDayYear
Date
Signature of Dr. Mitchell:

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Date:

MonthDayYear
Date
Witness Certification:

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Date:

MonthDayYear
Date
PATIENT REGISTRATION
Patient
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Preferred Pharmacy*
Pharmacy Phone*
Please enter a valid phone number.
Primary Care Doctor*
Primary Care Doctor Phone*
Please enter a valid phone number.
If the patient is the policy holder
Insurance Name
Insurance ID
Medicaid ID# (if applicable)
Responsible party (if not the same as the policy holder)
Name*

First NameMiddle Initial Last Name
Date of Birth

MonthDayYear
Date
Social Security #
Email Address
example@example.com
Address

Street, Apt, City, State, Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Policy holder
Name*

First NameMiddle Initial Last Name
Date of Birth

MonthDayYear
Date
Social Security #
Email Address
example@example.com
Address

Street, Apt, City, State, Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Place of Employment
Insurnace Company
Insurance ID
**If you have a secondary insurance policy, please inform us so we can provide you with a secondary form.
MEDICAL/DENTAL HISTORY
Patient Name*
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
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.
Are you under a physician's care? If yes, please explain.*

NoYes
Have you ever been hospitalized or had a major operation? If yes, please explain.*

NoYes
Have you ever had a serious head or neck injury? If yes, please explain.*

NoYes
Are you taking any medications, pills, or drugs? If yes, please list them.*

NoYes
Do you take, or have you taken, Phen-Fen or Redux? If yes, please list which and when you took them.*

NoYes
Have you ever taken Fosamax, Boniva, Actonel or any other mediations containing biphosphorates? If yes, please list which and when you took them.*

NoYes
Are you on a special diet?*

NoYes
Do you use tobacco?*

NoYes
Women: Are you...*

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?
Are you allergic to any of the following?*

AspirinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal Anesthetics
Do you use controlled substances? If yes, please explain.*

NoYes
Do you have, or have you had, any of the following?*

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsilitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow JaundiceNONE OF THE ABOVE
Have you ever had any serious illness not listed above? If yes, please explain.*

NoYes
Comments:
Please share any concerns you may be experiencing:
Does your child work with a speech therapist?*

NoYes
To the best of my knowledge, these questions have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Digital Signature of Patient, Parent or Guardian:*

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Date:*

MonthDayYear
Date
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.*

Yes, I give permissionNo, I do not give permission
Digital Signature of Patient/Guardian*

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Date*

MonthDayYear
Date
FINANCIAL AGREEMENT:
As our patient, we want to provide you the best care possible. There may be certain routine services that we feel are necessary for the maintenance of good oral health, which are not covered by insurance. You will be responsible to pay for all services not covered. CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE. I have read this policy and, by my digital signature, agree to pay for services not covered by my insurance as well as any legal and/or collection fees necessary for the collection of this debt.

ACKNOWLEDGEMENT OF RECEIPT:
I acknowledge that I have received and/or read a copy of Kentuckiana Pediatric Dentistry's Notice of Privacy Practices.

ASSIGNMENT AND RELEASE:
I assign Kentuckiana Pediatric Dentistry and Dr. Matthew C. Mitchell benefits, if any, otherwise payable to me for service(s) rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby authorize the Doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all of my insurance submissions whether manual or electronic.

The signature below is acknowledgement of HIPAA Consent, Notice of Privacy Policies, Medical Health Form (that was filled out for dependent), Insurance Authorization and Release and Financial Policies of this office.
Dependent Name*
Guardian Digital Signature*

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Emergency Contact*
Date*

MonthDayYear
Date
HIPAA Agreement
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 experience 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 the 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 conduction 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 of 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.
Guardian Digital Signature*

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Kentuckiana Pediatric Dentistry

NEW PATIENT INFORMATION FORM

PATIENT REGISTRATION

Patient

If the patient is the policy holder

Responsible party (if not the same as the policy holder)

Policy holder

MEDICAL/DENTAL HISTORY

PHOTO RELEASE

HIPAA Agreement