Medical Intake form

New Patient Registration Form
PATIENT INFORMATION
Patient Name*

FirstMiddleLast
Preferred Name
Email
example@example.com
Birth Date
Phone Number
Gender

MaleFemaleN/A
Height
Weight
What is the purpose of your visit today? DENTAL / AIRWAY / BOTH
Are You or Your Child in Pain

YesNo
MEDICAL HISTORY
Parent Name if Patient Is A Child*

FirstMiddleLast
Birth Date
Gender

MaleFemaleN/A
Are you or your child presently under the care of a physician for any medical disorder?

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

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

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

YesNo
If Yes, please indicate & reaction
Have you or your child 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?

YesNo
Please indicate if your child has 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
DENTAL HISTORY
Is this your child’s first visit to a dentist?

YesNo
Previous dentist, date, & service
How does your child receive fluoride?

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

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
INSURANCE INFORMATION
Dental Insurance
Medical Insurance
Subscriber ID/SSN
Subscriber
Person financially responsible for payment
Initial
Family/Responsible Party Information
ParentLegal Guardian
Number of children in family
Person Filling Out This Form (if not the Patient)

First NameLast Name
Marital Status

MarriedSingleDivorcedSeparatedWidow
Parent Name*

FirstLast
Parent Name*

FirstLast
MotherFather
MotherFather
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
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 my 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 for said child 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
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. Physical restraint by dentist/assistant/parent: The dentist restrains the child from movement by holding the child’s hands or upper body gently, stabilizing the child’s head between the dentist’s arm and body, or positioning the child firmly in the dental chair. This is for the safety of the child and to facilitate treatment.
6. 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.
The listed pediatric dentistry behavior management techniques have been explained to me. I understand their use, and the risks/benefits/alterations 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*
Signature*

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CONSENT/AUTHORIZATION FOR DENTAL TREATMENT
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
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/legal guardian, please complete this section:

I, (parent/legal guardian)

, cannot accompany my child,(child’s name) , to their appointment(s) with Terence QL Young, D.D.S.,.
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
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

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Date
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New Patient Registration Form

PATIENT INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

INSURANCE INFORMATION

Family/Responsible Party Information

AUTHORIZATION OF FINANCIAL RESPONSIBILITY

PATIENT MANAGEMENT TECHNIQUES

CONSENT/AUTHORIZATION FOR DENTAL TREATMENT