New Patient Form

New Patient Form

Welcome to Greater Houston Pediatric Dentistry!
We want to welcome your child into our practice. Our goal is to make his/her dental experience pleasant and eductional. Please provide us with all information requested so that we can better understand and care for your child.
CHOOSE YOUR GREATER HOUSTON PEDIATRIC DENTAL OFFICE LOCATION:*

Bunker Hill/Memorial CityKatyConroeHumble

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Patient Name*

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Birthday*

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Siblings & Ages
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Cell Phone:
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School:
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Child's Address:

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How Did You Hear About Us?*

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Name of Patient Who Referred You
Name of Dental Office or Pediatrician Who Referred You:

General Informed Consent

Greater Houston Pediatric Dentistry, PLLC
Greater Houston Pediatric Dentistry's goal is to provide complete oral health and create a comfortable environment for our young patients. We are committed to providing a safe and pleasant dental experience.

Our policy is to inform the parent/guardian before we perform any procedures and obtain verbal and written consent. The initial visit includes: a comprehensive clinical examination, diagnostic x-rays, a thorough dental cleaning, and preventive fluoride treatment.

If further dental treatment is needed, we put together a complete dental treatment plan with the recommended procedures and alternatives. Treatment procedures may include, but are not limited to: local anesthesia, controlled nitrous oxide-oxygen sedation ("laughing gas"), dental restorations, nerve treatment, crowns, extractions, and space maintainers. We will inform you of all treatment options, the risks and benefits of each, and the recommended treatment of choice for your child.

Pediatric dentistry differs from general dentistry in that with treating children, behavior dictates treatment. To obtain your child's cooperation, we practice a few behavior management techniques such as the "tell-so-do" method, modeling distraction, positive and negative reinforcement, passive stabilization, and voice control. Pharmacologic behavior management is also offered if these methods are unsucessful. If your child requires operative treatment/dental restorations, there exist some associated risks. These occur very rarely and include, but not limited to: numbness, sore gums, pain, infection, swelling, bleeding, bruising, discoloration, nausea, vomiting, allergic reactions, and aspiration or swallowing of a foreign object.

It is imperative that your child arrives promptly for all pre-scheduled appointments. We have reserved a time that has been dedicated for your child. If you are unable to arrive on time or if you need to reschedule an appointment, please contact us as early as possible.

If you have any questions regarding the information presented here, or any other aspect of our dental philosophy or patient management, please do not hesitate to ask us.

The signature of a parent or guardian affixed below authorizes the completion of all agreed upon dental procedures and the use of agreed upon methods. This consent shall remain in full force until cancelled by either party. Thank you in advance for your cooperation.
- I give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be adminstired by Dr. Luu or her supervised staff for diagnostic purposes and dental treatment of my child in my absence.
- I acknowledge that I have been given and offered a copy of the "Notice of Privacy Practices." I have read it and understand it, and all my questions have been answered.
Patient's Name*

First NameLast Name
Patient's Age*
Printed Name*
Your Relationship to Patient*
Signature*

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Date

MonthDayYear

Financial Policy

Greater Houston Pediatric Dentistry, PLLC
We welcome you to our practice and thank you for choosing Greater Houston Pediatric Dentistry for your child's dental needs. We strive to provide the best dental experience and oral health care for your child. It is our policy to make definite financial arrangments with you, the parent or legal guardian, before any treatment begins on your child. Our policy is outlined below. Please do not hesitate to ask any questions.
1. Payment is due in full at the time services are rendered. We accept cash, personal checks, debit cards and most major credit cards (MasterCard, VISA, American Express and Discover). If an extended payment plan is sought, we offer financing through the CareCredit program.
2. Payment is due in full at the time of the appointment for all new patient emergency visits.
3. All services rendered are charged directly to the parent or legal guardian of the patient, and the legal guardian is ultimately responsible for the account regardless of insurance coverage.
4. If you suspend or terminate dental care at Greater Houston Pediatric Dentistry, PLLC, any fees or services rendered will be immediately due and payable.
  
  Regarding dental insurance
5. You must provide us with accurate dental insurance information with the correct mailing address or a dental claim form provided by your employer.
6. As a courtesy to our patients, if we have recieved all your insurance information on the day of your appointment, we will gladly file the insurance claim for you.
7. You must be familiar with your insurance benefits. We are not responsible for and do not guarantee how your insurance company processes your claims or what benefits they pay per claim. You will be responsible for the deductible and the estimated portion not covered by your insurance, which is due at the time of treatment. Our estimates may be different than your insurance company's calculations; therefore, the amount due our office may be adjusted accordingly. You are responsible for paying all charges not covered by your insurance, including all fees above your insurance company's schedule of "allowable" or usual customary "UCR" fees. If you have questions about "UCR" fees, please ask.
8. Your insurance benefits are assigned to you, the patient, and is a contract between you and your employer. Your coverage amount depends on the quality of the plan purchased by your employer, not the fees of the practice.
9. By law your insurance company is required to pay each claim within 30 days of reciept. We file all insurance electronically, so your insurance company will recieve each claim within days of treatment.
10. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. Further insurance appeal will become your responsibility. We will gladly provide you with a claim form to assist you in following up with your insurance claim.
11. Should the fees for the professional services not be paid in accourance with the provisions herein, reasonable attorney's fees, plus applicable finance charges and disbursements, allowances and costs provided by law shall be included in the total amount due. If you have not paid your balance within 60 days, finance charges can be applied to all past due amounts at the rate of 1.5% per month (18% annual rate) until paid. If the account is in default and turned over for collection, a collection fee will be added. We will be glad to send a refund to you if your insurance pays us.
12. There will be a $30.00 service charge for all returned checks.
13. We value your time and appreciate patients who honor their scheduled appointments. There will be a $50.00 fee charged to parents that cancel with less than 24 hours of notice.
Authorization
I have read and accept the above Financial Policy for Greater Houston Pediatric Dentistry. I understand it and agree to the terms set forth regarding payment.
Printed Name of Responsible Party*
Relationship to Patient*
Name of Patient*

First NameLast Name
Signature of Responsible Party*

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Date*

MonthDayYear

Broken Appointment Charge

Greater Houston Pediatric Dentistry, PLLC
We reserve space in our office for you and your family to recieve care. Should you need to break your appointment, please let us know at least 24 hours in advance.

If an appointment is broken without advance notice, a $50.00 broken appointment fee will be assigned to your account. This is not covered through your insurance. This fee will become due as a part of your accounts balance, and it will need to be satisfied prior to scheduling future appointments.

Kindly give us notification so your appointment time can be given to another patient.

Phone number of office locations:

Katy, TX - 832-437-1110
Conroe, TX - 936-703-2131
Humble, TX - 281-852-1191
Bunker Hill/Memorial City, TX - 713-464-5437

Thank you for your cooperation.
Patient's Name*

First NameLast Name
Patient's Age*
Your Name*
Your Relationship to Patient*
Your Signature*

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Date*

MonthDayYear

Acknowledgement of Receipt of Notice of Privacy Practices

Greater Houston Pediatric Dentistry, PLLC
* You May Refuse to Sign This Acknowledgement *
I,Your Name* have received a copy of this office's Notice of Privacy Practices for my child. Name of Child*
Name of Responsible Party*
Signature

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Date*

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OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify)
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New Patient Form

Health Information

Who is Accompanying the Child Today?

Parent (or Guardian) Information

Emergency Information

Person Responsible for Account

Primary Insurance Information

General Informed Consent

Financial Policy

Authorization

Broken Appointment Charge

Acknowledgement of Receipt of Notice of Privacy Practices

OFFICE USE ONLY