CDHL: New Patient Form

Children's Dental Health of Lynchburg: New Patient Form
Patient Information
Child's Name*

First NameMiddle NameLast Name
Child's Preferred Name
Soc. Sec. #
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian Name*

First NameLast Name
Name of Person Bringing Child to Appointment*
How are you related to Patient?*
Do you have legal custody of the child?*

YesNo
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
**Our office uses phone, text, and emails as a way to remind you future appointments. Be sure to provide the phone mumber you would like the reminders sent to.**
If any, names and ages of siblings:
Medical History
Child's Physician*
Is your child being treated for any medical or mental health issues?*

YesNo
If yes, please explain:*
Is your child taking any prescriptions?*

YesNo
If yes, please list medications:*
Does your child have any allergies to medications or the environment?*

YesNo
If yes, please explain:*
Has your child ever been hospitalized?*

YesNo
If yes, please explain:*

Does the child have any of the following:*

	Yes	No
ADD/ADHD
Speech Difficulties
Asthma/Bronchitis
Autism
Cancer
Cerebral Palsy
Cold Sores
Heart Disease
Seizures
Diabetes
Heart Murmur
Hepatitis
HIV / AIDS
Loss of Consciousness
Pregnant
Prolonged Bleeding
Respiratory Problems
Sleep Apnea
Rheumatic Fever
Kidney Problems
Emotional Problems
Malabsorption Syndrome
Liver Disease
Fainting

Are there any other illnesses not listed above?*

YesNo
If so, please explain:*
Dental History
Does your child have a toothache or other dental problems?*

YesNo
If yes, please explain:*
My child sucks their thumb/fingers*

YesNo
Would you like sealants on your child's permanent molars if insurance covers the treatment? (Your child must be at least 5 years old)*

YesNo
Were you referred by another dentist?*

YesNo
If yes, who? (Doctor Name) Date of Last Visit? (Date MM/DD/YYYY)
Parent/Legal Guardian 1*

First NameLast Name
Relationship to Patient*
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
SSN
Employer*
Parent/Legal Guardian 2

First NameLast Name
Relationship to Patient
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
SSN
Employer
Custody Situation: Sole Custody/Joint Custody **If someone does not have legal rights to the patient named above, a copy of the custody order must be obtained for verification. Otherwise, single or divorced parents are assumed to have joint custody.
Insurance Information
In order to keep our fees reasonable, we do not bill for services rendered. Our policy is that you pay for treatment prior to services performed. Please check the appropriate Dental Insurance Plan you wish to use.

No InsurancePrivate InsuranceMedicaid
Policy Holder Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN*
Employer*
Dental Insurance Carrier*
Policy ID Number*
Medicaid ID Number
CONSENT
Your child is a minor, therefore, it is necessary that a signed consent be obtained from parent or legal guardian before any necessary dental services can be started. I understand that today’s visit is for a comprehensive dental examination, cleaning, fluoride, and x-rays (if needed). This office follows the guidelines of the American Academy of Pediatric Dentistry and recommends x-rays taken every 1-2 years. Current x-rays are necessary for a comprehensive dental examination. No restorative work will be scheduled without current x-rays. No exceptions. I grant Children’s Dental Health of Lynchburg permission to provide my child’s dental exam and treatment, and I will be responsible for the cost of this dental care.
Signature*

Clear
Date*

MonthDayYear
Date
Financial Agreement
By signing this agreement, I understand that I am responsible for ALL fees incurred by services performed by Children’s Dental Health of Lynchburg. I also understand that if my account balance becomes delinquent at any time, the outstanding amount can/will be transferred to a collection agency/attorney for recovery of the debt. If that occurs, I understand I will be charged interest in the amount of 24% annually, collection and/or reasonable attorney fees and any court fees which may occur with the collection of this amount due.
Signature*

Clear
Date*

MonthDayYear
Date
Appointment Policy
We, at Children’s Dental Health of Lynchburg, know how valuable your time is and we hope you feel the same about us. Consequently, we have a policy to protect our appointment schedule.

Sickness Policy
If your child is sick in any way either the night before or the day of a scheduled
appointment, or if you have an emergent situation, please call our office at your earliest convenience to reschedule.

Cancellation Policy
If you must cancel an appointment for other reasons, we require a call at least 24 hours prior to your scheduled visit, so that we may accommodate other patients. If you fail to provide proper notice, you may be subjected to a $35 cancellation fee.

Missed Appointment Policy
A missed appointment is defined as simply failure to arrive at an appointment without providing notification. Patients who miss appointments may also be subjected to a $35 missed appointment fee.
Also, if a second appointment is missed during the same 12 month period, the patient will be dismissed from our practice.

By signing this form, you acknowledge that you have read the policy, understand it, and accept it. You should also share this information with all persons who are responsible for bringing the patient to their visit.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Children's Dental Health of Lynchburg: New Patient Form

Patient Information

Medical History

Dental History

Insurance Information

CONSENT

Financial Agreement

Appointment Policy