New Pediatric Dental Patient Registration Form

New Pediatric Dental Patient Registration Form
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Preferred Nickname
Legal Gender*
Patient Age*
The Patient is...*

Is already scheduled for an upcoming consult with Southern Smiles Pediatric DentistryIs not yet scheduled and I will be contacting the practice to schedule soon
For children & college students, the patient’s current schooling is (skip if not applicable):

PublicPrivateHomeschoolUniversity/College
Name of School Patient Attends
Name of Adult Contact #1 (adult patients enter your own name and information)*

First NameLast Name
Relationship to Patient*
Mobile Phone Number for Adult Contact #1*
Please enter a valid phone number.
Email Address for Adult Contact #1*
example@example.com
Address for Adult Contact #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Adult Contact #2 (adult patients enter your own name and information)

First NameLast Name
Relationship to Patient
Mobile Phone Number for Adult Contact #2
Please enter a valid phone number.
Email Address for Adult Contact #2
example@example.com
Address for Adult Contact #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a custodial agreement that requires mutual consent for treatment?

YesNo
Enter the name(s) of all who will be financially responsible for the patient
Dental Insurance
Is your child covered by dental insurance?*

YesNoUnsure
Select all that apply to your child’s insurance:*

No dental insuranceCovered by traditional dental insurance policyChild is also covered by a secondary insurance policyCovered by state MEDICAID dental insuranceCovered by state HEALTH CHOICE CHIP dental insurance
Please enter the information for the policy below:
Subscriber Name

First NameLast Name
Subscriber DOB

MonthDayYear
Date
Subscriber Address If Different From Patient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber ID
Subscriber SSN
Group #
Insurance Company
Provider Phone Number
Please enter a valid phone number.
Employer
Current Dentist Information
Do you have any other children who are our patients in our practice?*

YesNo
Name of Patient’s Previous Dentist
Location of Patient’s Previous Dentist
The patient had a dental exam and cleaning...*
The patient had a radiographs / X-rays in the past...*
The patient has been evaluated by an orthodontist in the past*

YesNo
Does your child drink fluoridated water?*

YesNo
What is the main source of your child’s drinking water (not municipal city water)?*
Does your take any fluoride supplements?*

YesNo
Is your child using fluoridated toothpaste to brush?*

YesNo
What kind of toothpaste is your child using?*
How often are your child’s teeth brushed / cleaned?*
How often are your child’s teeth flossed?*
Does your child have any ongoing oral habits? If yes, please specify:
Is there a family history of cavities / tooth decay?*

YesNo
Is there a history of trauma to primary / baby teeth?*

YesNo
Is there a history of trauma to permanent adult teeth? (If yes please provide details).*
Has the patient experienced injury to the face or jaws? (If yes please provide details).*
Does the patient have anxiety about dental appointment appointments? (If yes please provide details).*
Are antibiotics required prior to invasive dental procedures? (If yes please provide details).*
Does your child consume the any of the following on a daily or weekly basis? Select all that apply:*

Drink Soda/Carbonated BeveragesJuice Boxes with SugarFruit JuicesFruit Snacks in Sugar WaterSticky Fruit SnacksSugary CandyGummy Chewy VitaminsSports DrinksEnergy DrinksChewing Gum that has SugarNone, Not Applicable
Please describe any concerns you have about your child’s teeth:*
Name of Child's Pediatrician*
Approximated Date of Last Regular Medical Check-Up

MonthDayYear
Date
MEDICAL, HEALTH & DEVELOPMENTAL HISTORY
Is your child generally in good health?*

YesNo
Have you ever been told by a physician your child needs to have Prophylactic Antibiotics prior to dental treatments?*

YesNoUnsure
Has your child ever been seriously ill? (If yes please provide details).*
Has your child ever been hospitalized? (If yes please provide details).*
Has your child ever had any surgeries or operations? (If yes please provide details).*
Was your child born prematurely or were there any difficulties at birth? (If yes please provide details).*
Please List All Medications (Prescription, Over The Counter, Vitamins or Supplements), dosages and dates started to the best of your knowledge. Write “none” if this is the case.*
Is The Patient Allergic To Or Had Any Unusual Reactions To Any Of The Following (select all that apply):*

LatexPenicillinRed DyeSulfa DrugsTree NutsDairyFood AllergiesOtherNone
Please list any other allergies we should be aware of
Please select Yes or No regarding the following conditions as they pertain to the patient:*

Endocrine DisorderDizziness, Vertigo, FaintingDiabetes/Hypoglycemia/HyperglycemiaDevelopmental Disorder/Learning DisordersDepressionCystic FibrosisCongenital Birth DefectsCleft Lip/PalateCerebral PalsyCancerBleeding DisorderBladder/Kidney ProblemsBipolarAutoimmune DisorderAutism/Autistic SpectrumAsthma/Reactive Airway DiseaseArthritis/ScoliosisAnemia/Sickle Cell Disease/BloodAbnormal Bleeding/BruisingAIDS/HIVADD or ADHDVision ImpairmentTuberculosisStrokeSpina BifidaSpeech DelaySnoringSeizures/EpilepsyRheumatic FeverPneumoniaMental Developmental DelayMental Health CareLiver DiseaseHormone/Endocrine DisordersKidney DiseaseHigh Blood PressureHepatitisPhysical Developmental DelayHeart ComplicationsHearing ImpairmentHeadaches/MigrainesGERD or Acid RefluxNone of the Above
Any additional medical history comments or conditions:
Who may we thank for referring you to our practice? Check all that apply:

Current Family DentistPediatricianHygienist/Assistant/Dental Team MemberExisting Family MemberWord of Mouth in CommunitySocial MediaOnline Mom's GroupInternet Search EngineNone
Is there someone specific we may send a thank you to?
RADIOGRAPH / X-RAY ACKNOWLEDGMENT & PERMISSIONS
Radiograph / X-Ray Acknowledgment & Permissions Radiographs (X-Rays) are likely to be recommended at your child’s dental exam. Please read both statements below and select an answer option:

Statement # 1: In the event that new dental X-rays are recommended by the doctor, I understand that I will be notified in advance prior to any X-rays being taken. I understand that not all X-rays may be covered by my dental insurance. I understand that I am responsible for all fees if my insurance company does not cover all or a portion of the X-rays.

Statement # 2: I DO NOT grant permission for dental X-rays to be taken at the initial exam and I will discuss my concerns with the doctor. I understand that there are numerous dental diseases and pathology that cannot be diagnosed without the use of dental X-rays. I hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral or systemic health conditions possibly present that are not fully diagnosed or remain undiagnosed as a result of opting out of dental radiographs.
I have read statements 1 & 2 and grant permission for X-rays.I have read statements 1 & 2 and DO NOT grant permission for X-rays.
Optional: You may upload images such as X-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.

Cancelof
Review & Acknowledgement of Practice Policies
NEW PATIENT CONSULT APPOINTMENT CANCELLATION & RESCHEDULING POLICY

To cancel your appointment, please notify our office at least twenty-four (24) hours in advance of your scheduled appointment time. Appointment changes can only be accepted during regular office hours. Less than twenty-four hours advanced notice during regular business hours is considered a missed / no-show appointment. Rescheduling a consultation appointment may incur a fee that is collected prior to rescheduling.

PRIVACY DISCLOSURE STATEMENT & ACKNOWLEDGEMENT

This section is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. It discloses to you how we normally operate and your acknowledgment thereof. The digital signature at the conclusion of this form does hereby signify that the undersigned does hereby attest to having been afforded the opportunity to review the Matthew David McNutt, DDS, MS, PA notice of privacy policy noted below. Patients / Parents / Guardians have the right to review our notice of privacy policy prior to signing this consent. You have the right to request restrictions on the use of your protected health information. We value protecting private patient information and have implemented layers of protection and staff training. This disclosure does serve as notice that: Full initial examinations generally occur in a private consultation room. It is customary for patients upon arrival to use our digital check-in device (iPad) to signify their arrival for a scheduled appointment, and this device displays the legal name of the patient. Our orthodontic treatment facilities operate with an ‘open-bay’ concept in the main clinic (no partitions or physical visual barriers between patient treatment chairs). This creates a fun and welcoming environment. Patients, their family members, and the staff will be present. Despite our best efforts to operate in a respectful and discrete manner, it is not possible within the practice to guarantee full privacy of all protected health information. A copy of the full privacy disclosure statement is available on our website and in the office.

POLICIES REGARDING FINANCIAL ARRANGEMENTS & INSURANCE BENEFITS

Our practice has established Policies Regarding Financial Arrangements & Insurance Benefits for patient care provided by Matthew David McNutt, DDS, MS, PA. A copy of this document is available on our website and in the office. The digital signature at the conclusion of this form does hereby signify that the undersigned has been informed of this and will be afforded the opportunity to review these policies prior to pursuing treatment with our practice.

NEW PATIENT EXAMINATION EXPECTATIONS & FEES: Most of our new patient examinations are at no charge and others do incur a fee. This will vary depending on the type of exam and the circumstances. After reviewing the completed registration packet, our treatment coordinator will contact you in advance to discuss any examination fees prior to the scheduled consultation. The number of exams we schedule each day is considerably less than most orthodontic practices and is limited to 4-5. This is one reason for our careful screening process. We also limit the time of day we are willing to schedule new patient examinations. We realize that other offices may offer more convenient times as well. However, we understand that it is nearly impossible for an orthodontist to spend 20-30 minutes of quality time with 8-12 new patients a day, and still be hands-on with patients who are actively in treatment in the clinic. During the highly desirable early morning and after school hours Dr. McNutt is hands-on with his team, instead of delegating everything in order to see more new patient exams.

RELEASE FORM FOR MEDIA USE
We are passionate about creating a lifetime of healthy teeth and beautiful smiles. One of the best ways to share our enthusiasm and educate people is to share images of our team having fun with patients in the office and to share our work. We want to create positive and reassuring examples of good oral health within the community. We often do this by sharing content we have created in the office, on our website and on social media. Images/videos of patients may be a part of that media. We treat the privilege of sharing our work with great respect.
Please select all of your preferences / permissions that apply below:*

I hereby grant permission to use patient images and media obtained as described above to promote the practice and to promote good oral health within the community.I also grant permission for our family to be 'tagged' on social media in conjunction with our postsI DO NOT grant permission to use patient images and media obtained as described above.
Please understand that you have the right to revoke permission or grant permission in the future as you see fit.

AUTHORISATION & DIGITAL SIGNATURE CONSENT FOR NEW PATIENT EXAMINATION
The digital signature of the undersigned at the conclusion of this form does hereby grant and convey:
- Consent to allow Dr. Matthew David McNutt, DDS, MS, PA to conduct an orthodontic examination of the aforementioned patient.
- Understanding the examination will include diagnostic photographs (teeth and facial features).
- Understanding that in order to complete at full exam we will usually need to evaluate a recent panoramic radiograph.
- Consent to obtain a copy of the most recent panoramic radiograph (X-ray) from your family dentist.
- Consent as necessary to obtain a new panoramic radiograph in our office the day of the examination, unless specifically prohibited by you at the exam, as is your right.
- Understanding that in the event that permission to obtain diagnostic radiographs / X-rays is denied prior to, during and after treatment, the undersigned does hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral conditions possibly present that are not fully revealed or are undiagnosed as a result of opting out of dental radiographs.
- Understanding that treatment options and estimated treatment fees may be discussed.
CONSENT TO RELEASE RECORDS & CORRESPOND WITH OTHER DOCTORS:
The digital signature at the conclusion of this form does hereby grant and convey permission to:
- Release records to and correspond with the patient’s dentist of record.
- Release records to and correspond with specialists for procedures related to the patient’s recommended treatment plan.
Furthermore, the undersigned does hereby attest to:
- Having read, understood, and completed this registration packet accurately.
- Understands and agrees to abide by the policies herein.
- Grants or denies permissions as selected herein.
- Furthermore, the undersigned is responsible for informing our practice of any changes to the patient’s contact information, changes in insurance and changes to medical status / history.
- Having the authority to sign below.
Your Signature*

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New Pediatric Dental Patient Registration Form

Dental Insurance

Current Dentist Information

MEDICAL, HEALTH & DEVELOPMENTAL HISTORY

Review & Acknowledgement of Practice Policies