Dentistry for Children- Patient Information Update Form

INSURANCE INFORMATION
Primary Insurance
Insured's Full Name
Date of Birth

MonthDayYear
Date
Employer
Insurance Company Name
Member ID
Group #
Secondary Insurance
Insured's Full Name
Date of Birth

MonthDayYear
Date
Employer
Insurance Company Name
Member ID
Group #
Medical Insurance
Insured's Full Name
Date of Birth

MonthDayYear
Date
Employer
Insurance Company Name
Member ID
Group #

AUTHORIZATION STATEMENTS
I do hereby authorize Dr. Schreiber, doctors and the staff of Dentistry for Children, PC to provide my child with diagnostic and therapeutic procedures, including dental x-rays and photographs, as may be necessary for proper dental care.
(Initial)
I do hereby understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment by using praise, explanation, and demonstration of procedures and instruments using variable voice tones. I authorize this Dental Office to administer such medication, including the use of nitrous oxide (“laughing gas”), which is a mild sedative that is inhaled to reduce anxiety and/or the use of a mouth prop.
(Initial)
I do hereby authorize payment directly to this Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment and that any estimate given to me is not guaranteed. I authorize the release of any information relative to all claims. The undersigned accepts the fee charged as a lawful debt and promises to pay said fee including the cost of collection, a reasonable attorney fee of 33.33% and court costs, waiving now and forever the right to claim exemption under the constitution and laws of the State of Alabama or any other state.
(Initial)
I acknowledge that my copay is expected at the time of service and that any unpaid copay is subject to a $20.00 fee and, after 90 days, a monthly billing fee of $2.00, and a fee of $50 for missed or canceled appointments without a 24 hour notification.
(Initial)
I acknowledge that I have read your Notice of Privacy Practices in accordance with The Health Insurance Portability & Accountability act of 1996 (HIPAA), and have been offered a copy of it.
(Initial)
Whom may we release information to?
Permission to share:

I AGREE and grant full permission for Dentistry for Children to use either myself or my child’s FIRST NAME & PHOTOGRAPH in any publication or advertising materials (printed or electronic). This consent always waives the rights of privacy or compensation for the use of photo or name.I AGREE and grant full permission for Dentistry for Children to use either myself or my child’s PHOTOGRAPH ONLY, in any OR publication or advertising materials (printed or electronic). This consent always waives the rights of privacy or compensation for the use of photo.I DO NOT AGREE to have mine or my child’s information or photograph used.
Signature:
Signature of:

MotherFatherGrandparentGuardian
Date

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
ADD/ADHD
AIDS/HIV
Allergies (specify below)
Asthma
Autism
Blood Disorder
Cancer
Cerebral Palsy
Developmental Delay
Diabetes
Down Syndrome
Emotional Problems
Epilepsy
Eye disease
Ear problems (other than tubes)
Fainting
Heart Condition (specify below)
Hepatitis
Kidney Condition
Liver Condition
Mental Disability
Physical Disability
Sickle Cell
Seizures
Special Needs (specify below)
Speech Problems
Stomach/GI Disease
Tuberculosis
Other

Dentistry for Children - Patient Information Update Form

FAMILY INFORMATION

INSURANCE INFORMATION

PATIENT’S DENTAL HISTORY

PATIENT’S MEDICAL HISTORY

AUTHORIZATION STATEMENTS