Mt. Sterling Kids: Existing Patient Form

Mt. Sterling Kids: Existing Patient Form
Patient's Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Soc. Sec. #*
Today's Date*

MonthDayYear
Date
Gender*

MaleFemale
Guardian's Contact Information
Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Home Phone Number*

Area CodePhone Number
Driver's License #
Date of Birth*

MonthDayYear
Date
Relationship to child*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship
Who referred you to us?
Please select at least one:

BillboardMagazineReferral CardBuilding SignageMedibagsSchool SponsorshipsCommunity SponsorshipsNewspaperSocial MediaDentist or Other DoctorPhonebookTVGoogleRadioWord of Mouth (WOM)Insurance / Directory
Please list the provider or office name:*
Dental Insurance
Insurance Information*

I don't have dental insuranceI have dental insurance (please complete the following sections below)
Primary Dental Insurance Holder
Primary Dental Insurance Holder*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
SSN*
Relationship to Patient*
Primary Dental Insurance Employer
Employer Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Dental Insurance
Insurance Company
Phone Number

Area CodePhone Number
Subscriber ID
Group Number
Secondary Dental Insurance
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
SSN
Relationship to Patient
Secondary Dental Insurance Employer
Employer Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Dental Insurance
Insurance Company
Phone Number

Area CodePhone Number
Subscriber ID
Group Number
Child Medical History
Medical History
Physician Name*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
Are all immunizations up to date?*

YesNo
Does the child require premedication (Antibiotics) for dental work? (Due to a medical condition)*

YesNo
Is the child currently taking any medications / supplements?*

YesNo
If yes, please list them
Is the child allergic to any medications / materials / foods?*

YesNo
If yes, please list them
Has the child ever tested positive for COVID?*

YesNo

Does the child have or ever had any of the following:*

	Yes	No
Abnormal bleeding
Acid Reflux
ADD
ADHD
Anemia
Anxiety
Apraxia / Speech Disorder
Artificial or Problems with Bones / Joints / Muscles
Artificial Heart Valve
Asthma
Autism / Asperger's / PDD
Blood Transfusions
Cancer
Cerebral Palsy
Circulatory Problems
Cleft Lip / Palate
Cold Sores
Counseling or Therapy
Congenital Heart Condition
Convulsions / Epilepsy / Neurological Disorders
Depression
Developmental Delay
Dizziness or Fainting
Down Syndrome
Eating Disorder
Endocrine or Gland Disorders (Diabetes, Thyroid, Pituitary)
Epinephrine Sensitivity
Fetal Alcohol Syndrome
GERD / Reflux
Handicaps / Disabilities
Hearing Impairment
Head Injury
Heart Murmur
Hemophilia
High Blood Pressure
HIV / AIDS
Hives / Skin Condition
Hyperthyroidism
Hypothyroidism
Kidney / Liver Condition
Leukemia
Low Blood Pressure
Lymphoma
Mental Health Disorders
Metabolic Disorder
Migraines / Headaches
Operations / Hospital Stays
Organ Transplant
Pacemaker
Persistent Cough
Premature Birth
Psychiatric Care
Radiation Therapy
Respiratory Disease
Rheumatic Fever
Sensory Integration
Shortness of Breath
Sickle Cell Anemia
Sinus Problems
Sleep Apnea
Stroke
Swelling / Edema
TMJ Disorder
Tuberculosis (TB)
Tumor
Ulcerative Colitis
Ulcers
Vascular Malformation
Vision Problems
Vitamin Deficiency
Xerostomia / Dry Mouth
Other

Pharmacy Name
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Fax

Area CodePhone Number
HIPAA
NOTICE OF PRIVACY PRACTICES
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 explanation 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 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 conducting 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 to 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.
Signature*

Clear
Date*

MonthDayYear
Date
Office Policies

Important: Do not sign this form without reading and understanding its content.
In an effort to provide the highest quality dentistry, we require a 24 hour NOTICE for any schedule changes. If you are more than 10 minutes late for the appointment you may be asked to reschedule. Our office understands that sometimes emergency situations arise and we will handle each circumstance on an individual basis.

Three missed appointments(per family) or appointments cancelled less than 24 hours will result in the dismissal from our practice. We reserve the right to schedule siblings on different day's if there have been multiple broken appointments.

A PARENT OR LEGAL GUARDIAN(WITH PROPER PAPERWORK) MUST BE PRESENT AT THE FIRST APPOINTMENT. FAILURE MAY RESULT IN THE APPOINTMENT BEING RESCHEDULED.

I have read, understand and agree to the Missed & Late Appointment Policies as stated above. This consent will remain valid indefinitely
unless revoked in writing.
Guardian's Name*

First NameLast Name
Guardian's Signature*

Clear
Date*

MonthDayYear
Date
Non-Guardian Treatment Consent Form

Please list the name of an individual that is not your child's guardian, mother, or father, but is given your permission to bring your child to their appointment.
I, (parent/guardian name) , give Mount Sterling Pediatric Dentistry permission to treat/see (child's name), while I am not present.
The individual bringing my child to the appointment is named, (adult accompanying child) and is at least 18 years of age. Their relationship to the patient is (Relationshop to the patient) .
The following individuals that are at least 18 years of age are also permitted to bring my child to the appointment.
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to Patient
I also give this individual permission to sign the treatment plan and make decisions regarding my child's
- Dental Treatment including fillings, extractions and stainless steel crowns.
- Medical treatment(if necessary should an emergency arise)
- Behavior management including the use of nitrous oxide and/or protective stabilization.
I understand payment is expected at the time of treatment.
Parent contact information for questions regarding treatment of the child:
Parent Name*
Contact Info: (Cell)
Contact Info: (Home)
Contact Info: (Work)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Signed (parent or guardian)

Clear
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

Mt. Sterling Kids: Existing Patient Form

Patient's Information

Guardian's Contact Information

Emergency Contact Information

Who referred you to us?

Dental Insurance

Primary Dental Insurance Holder

Primary Dental Insurance Employer

Primary Dental Insurance

Secondary Dental Insurance

Secondary Dental Insurance Employer

Secondary Dental Insurance

Child Medical History

Medical History

HIPAA

NOTICE OF PRIVACY PRACTICES

Office Policies

Non-Guardian Treatment Consent Form

Parent contact information for questions regarding treatment of the child: