Child New Patient Form

Child New Patient Form
NOTICE TO PARENT OR GUARDIAN

We require the presence of the patient’s parent or legal guardian during the initial exam to ensure accurate understanding of the extensive information that will be provided. Thank you for entrusting Dr. Layfield with your orthodontic care.
Patient Information
Name

First NameMiddle InitialsLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Preferred contact method

Mobile PhoneHome PhoneWork PhoneEmail
Attending School
Grade Level
Patient interests or hobbies
Primary Responsible Party
Relationship to Patient

MotherFatherStep-MotherStep-FatherGrandparentOther
Name

First NameMiddle InitialsLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Marital Status

SingleMarriedDomestic PartnerSeparatedDivorcedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Preferred contact method

Mobile PhoneEmail
Secondary Responsible Party
Relationship to Patient

MotherFatherStep-MotherStep-FatherGrandparentOther
Name

First NameMiddle InitialsLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Marital Status

SingleMarriedDomestic PartnerSeparatedDivorcedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Preferred contact method

Mobile PhoneEmail
Responsible Parties Employer

Primary Responsible Party
Employer Name
Occupation
Secondary Responsible Party (optional)
Employer Name
Occupation
Family Referral
Name and age of additional children in the family
Are any family members active or previous patients of Dr. Layfield?

YesNo
If yes, please list patient’s name
How did you hear about our office?

Dentist ReferralFamily/friend referralGoogle SearchCommunity Event
Please name either the dentist or family friend that referred you. If you met us at a community event, please tell us which one:
General Dentist Information
Have you had a dental visit in the last 6 months?

YesNo
Dentist Name
Treatment Options
What treatment option(s) is the patient interested in?

InvisalignTraditional BracesRetainers
Insurance Standard
We ask that you realize we don’t work for an insurance company, but we do work for our patients. Most insurance companies provide great benefits for our patients and we’re going to do everything we can to maximize your benefits. Please understand that the fees we charge and the treatment that we’re going to recommend is specifically designed for your individual needs and never based on your insurance coverage.
Do you have Orthodontic Insurance?

YesNo
Primary Dental Insurance
Primary Insurance Company
Member ID / Policy #
Group Number
Policy Holder First and Last Name
Patient Relationship to Insured

SelfSpouseOther
Insured Date of Birth

MonthDayYear
Date
Policy Holder Employer
Insured Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Contact Number
Please enter a valid phone number.
Secondary Dental Insurance
Secondary Insurance Company
Member ID / Policy #
Group Number
Policy Holder First and Last Name
Patient Relationship to Insured

SelfSpouseOther
Insured Date of Birth

MonthDayYear
Date
Policy Holder Employer
Insured Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Contact Number
Please enter a valid phone number.
Has your child had previous orthodontic treatment?

YesNo
What is your primary concern(s)?
Patient History
Has the patient reached puberty?

YesNo
Please list any medication the patient is currently taking
Does the patient have any allergies? If yes, please list below
Check if you have or have had any of the following:
Other/details
Indicate any history of (check all that apply). If checked, please explain:
Other/details
Type a question

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Date

MonthDayYear
Date

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

- Obtaining payment from third-party payers (e.g. my insurance company);

- The day-to-day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of, your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restriction on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Date

MonthDayYear
Date
Patient Name

First NameLast Name
Relationship to Patient
Signature

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Child New Patient Form

NOTICE TO PARENT OR GUARDIAN

Patient Information

Primary Responsible Party

Secondary Responsible Party

Responsible Parties Employer

Family Referral

General Dentist Information

Treatment Options

Insurance Standard

Patient History

Health Insurance Portability and Accountability Act of 1996 (HIPAA)