Medical Intake form

New Patient Registration Form
PATIENT INFORMATION
PATIENT NAME*

FirstMiddleLast
Preferred Name
Email (Guardian's email if minor)
example@example.com
Birth Date*
Phone Number*
Height
Weight
Patient Gender: Male ____ Female _____ Prefer Not to Identify _____
What is the purpose of your visit today? DENTAL / AIRWAY / BOTH
Is Patient in Pain

YesNo
Parent / Guardian Name if Patient Is A Child*

FirstMiddleLast
Parent / Guardian Birth Date*
PATIENT MEDICAL HISTORY
Are you presently under the care of a physician for any medical disorder?

YesNo
If Yes, describe
Have you ever had surgery or been hospitalized for extensive care?

YesNo
If Yes, date and reason?
Do you take any medication regularly or taking any medications currently?

YesNo
Medication / Dose
Are you allergic or sensitive to any foods or medications?

YesNo
If Yes, please indicate & reaction
Have you experienced any unfavorable reactions to previous dental or medical care?

YesNo
If Yes, when and what happened?
Is your child’s immunizations up to date?

YesNoN/A
Please indicate if you have had any of the following:

AnemiaAsthmaADHDAutismAIDS / HIVBleeding ProblemsCerebral PalsyChicken poxCleft Lip / PalateDiabetesDown SyndromeEmotional ProblemsEye ProblemsHandicap / DisabilitiesHearing ProblemsHeart ConditionsHeart MurmurHigh Blood pressureHepatitisJaw Problems (TMJ)Kidney ProblemsLearning DisabilitiesLeukemiaLiver DiseaseMeaslesMentally DisabledMumpsRecurrent HeadachesRheumatic FeverSeizuresSpeech ProblemsTuberculosisTumors / CancersThyroid ProblemsOther
PATIENT DENTAL HISTORY
If patient is a child, is this your child’s first visit to a dentist?

YesNo
Previous dentist, date, & service
Do you use fluoride?

NoneDrops / TabsRinseToothpaste
How often do you brush your teeth?
How frequently do you eat / drink sugary foods, candy, soda, juice, etc between meals?
Do you wear a mouth guard?

YesNo
Have there been any injuries to teeth or jaw (falls, blows, chips, etc?)

YesNo
Incident (Please Explain):
Have any members of your family had any unusual dental problems?

YesNo
Incident (Please Explain):
Patient / Parent Signature*

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Date*

MonthDayYear
Date
Relationship (Parent / Guardian / Self)
INSURANCE INFORMATION
Dental Insurance
Medical Insurance
Subscriber ID/SSN
Subscriber
Person financially responsible for payment
Person Filling Out This Form (if not the Patient)

First NameLast Name
If Child, Parent / Guardian Name*

FirstLast
If Child, Parent Name*

FirstLast
MotherFather
MotherFather
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Please text message appointment reminders to the following cell phone:
Who may we thank for referring you to our office?
AUTHORIZATION OF FINANCIAL RESPONSIBILITY
1. I hereby authorize Terence QL Young, D.D.S., Inc. to perform any and all dental treatment and to use such methods, drugs and agents as seen advisable. This authorization shall remain in effect until cancelled.

2. I hereby assume any and all financial responsibility and hereby assign payment of all dental care insurance benefits to Terence QL Young, D.D.S., Inc and assume responsibility for fees not covered by my group insurance.

3. I hereby authorize Terence QL Young, D.D.S., Inc. to provide any insurance company(s), claim administrators(s), and consulting health care professionals with information concerning health care, advice, treatment, or supplies provided. This information will be used exclusively for the purpose of evaluating and administering claims for benefits.

I understand I am responsible for all charges or fees incurred and co-payments must be made at the time of service as our financial policy states. We will gladly process payments over the phone if a credit card is used.
Signature*

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Date*

MonthDayYear
Date
Relationship
PEDIATRIC PATIENT MANAGEMENT TECHNIQUES
Every effort will be made to obtain the cooperation of dental patients by the use of warmth, friendliness, humor, gentleness, kindness, and understanding. Should the dental patient exhibit signs of anxiety we will use pediatric dentistry behavior management techniques to obtain their confidence and cooperation. These management techniques are all routinely used to gain cooperation of your child, eliminate uncooperative behavior, or prevent the child from self-injury.

All techniques are accepted by the American Academy of Pediatric Dentistry:
1. Tell-show-do: The dentist explains to the child what is to be done, then shows the child what is to be done by demonstration. Then the procedure is performed in the child’s mouth as described. Praise is used to reinforce cooperative behavior.
2. Positive reinforcement: This technique rewards the child who displays any behavior which is desirable. Rewards included compliments, praise, a pat on the back, or a prize.
3. Voice control: The attention of a disruptive child is gained by changing the tone or increasing the volume of the dentist’s voice. What is said is less important than the abrupt or sudden nature of command.
4. Mouth props: A rubber or plastic device is placed in the child’s mouth to prevent closing when a child refuses or has difficulty maintaining an open mouth.
5. Nitrous Oxide (Laughing gas): This is administered to calm and soothe the patient prior to a stressful procedure. Nitrous oxide is a very safe medication that rarely causes nausea. The patient does not sleep, unless already tired before the appointment. Parental permission required.
The listed pediatric dentistry behavior management techniques have been explained to me. I understand their use, and the risks / benefits / alternatives available. I have had all my questions answered and I realize I can always seek further information or revoke permission for any of these techniques.

I acknowledge that I have read and understand this consent form, that I have been given an opportunity to ask any questions I may have, and that all questions about the behavior management techniques described have been answered in a satisfactory manner. I give my consent to needed dental services and use of proper and acceptable methods to complete the treatment for my child, Child's Name*
It is the policy of Young Breath and Wellness (Terence QL Young, D.D.S., Inc) that all minors be accompanied by a parent or legal guardian for their dental visits. We do understand that under certain circumstances, you would prefer another caregiver to accompany them.

All minors seeking dental treatment MUST be accompanied by a parent / legal guardian during the initial office visit. After the initial appointment, a minor may be seen for treatment only with written authorization from the parent / guardian under the conditions specified in this consent. If you need to send your child to their appointment with an adult other than yourself or a legal guardian, please let our front desk know in writing. Or, you may use the following fields to assign persons who are authorized to accompany your child:
Name
Name
Relationship
Relationship
Parent / Guardian Signature*

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CONSENT / AUTHORIZATION FOR DENTAL TREATMENT
Patient and/or Parent / Guardian Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Consent Conditions (check all that applies below):

the consent to sign any and all forms required to give permission to Terence QL Young, D.D.S. to treat the dental needs of myself or my childthe consent to perform: exam, x-rays, cleaning, fluoride treatment, and any other dental treatment deemed necessary by Terence QL Young, D.D.S.the consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges)the consent to the dental practice to discuss my or my child's future dental treatment needs (i.e. treatment plans)the consent to sign my or my child’s treatment plan once it has been presented by the dental staff. I understand this does not obligate me to the treatment, only that the office has informed me or my representative of the dental needs of myself or my childthe consent to schedule future dental visits for myself or my child
Parent / Guardian Signature:

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Date

MonthDayYear
Date
Should be Empty:

New Patient Registration Form

PATIENT INFORMATION

Patient Gender: Male ____ Female _____ Prefer Not to Identify _____

PATIENT MEDICAL HISTORY

PATIENT DENTAL HISTORY

INSURANCE INFORMATION

AUTHORIZATION OF FINANCIAL RESPONSIBILITY

PEDIATRIC PATIENT MANAGEMENT TECHNIQUES

CONSENT / AUTHORIZATION FOR DENTAL TREATMENT

Patient Gender: Male __ Female _ Prefer Not to Identify ___