New Patient Registration-- John B. Witte, DDS, PC

Children's Dentistry
John B. Witte D.D.S., P.C.
3035 Matlock Road Arlington, TX 76015
Phone: 817-784-1000
Brush, Floss, Smile!
New Patient Registration
Patient Information
Child's Name:*

First NameLast Name
Preferred Name:
Date of Birth:*

MonthDayYear
Date
Age:*
Gender:

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
Cell Phone:
Email Address:*
example@example.com
Primary Phone Number for Appointment Confirmation:*
Sibling Name & DOB:
Sibling Name & DOB:
Parent Information
Mother's Name:*
DOB:*

MonthDayYear
Date
SSN:*
Cell Phone:*
Email:*
example@example.com
Employer:*
Father's Name:*
DOB:*

MonthDayYear
Date
SSN:*
Cell Phone:*
Email:*
example@example.com
Employer:*
Emergency Contact
Name:*
Relationship:*
Phone:*

Dental Insurance Information
Primary
Subscriber Name:*
DOB:*

MonthDayYear
Date
SSN:*
Employer:*
Insurance Company:*
Group #:*
ID #:*
Secondary
Subscriber Name:
DOB:

MonthDayYear
Date
SSN:
Employer:
Insurance Company:
Group #:
ID #:
Accompanying Your Child
A parent or legal guardian must be present during all restorative treatment appointments. Please list any person(s), other than legal parents/guardians, who are authorized to accompany your child to any future routine dental visits.
Name*
Relation*
Name*
Relation*
(Authorized person(s) must present proper identification upon arrival)
None; only legal parents/guardians may accompany
Referral Information
How did you hear about our office?
Referral Source

FriendDentistPediatricianOnlineOther
Consent & Authorization
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in strictest
confidence and it is my responsibility to inform this office of any changes in my child's medical status.

I authorize the dental staff at Children's Dentistry - John B. Witte D.D.S., P.C. to perform the necessary dental services my
child may need.
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date

Children's Dentistry
John B. Witte D.D.S., P.C.
3035 Matlock Road Arlington, TX 76015
Phone: 817-784-1000
Brush, Floss, Smile!
Appointment Policy
Thank you for choosing our office as your child's dental home. We are committed to providing the highest quality care and service to you and your family.
Children tend to do better in the dental office when they are not tired. We encourage morning appointments, especially for pre-school or nervous children. For many, even a small filling at the end of a long day can feel overwhelming. Please remember that dental appointments are considered excused absences from school.
If your child is over the age of 3, we ask that you allow them to accompany our staff through the dental experience while you wait in the reception area. Separation anxiety is not uncommon in children, so please try not to be concerned if your child exhibits some negative behavior. This is normal and will soon diminish. We are all specifically trained in helping young children overcome anxiety. Our experience has shown that most children over the age of 3 react more positively when permitted to experience the dental visit on their own and in an environment designed for children.
We strive to see all patients on time for their scheduled appointment. There are times when our schedule is delayed in order to accommodate an anxious child or an emergency. Please accept our apology in advance should this occur during your appointment. We promise to give the same courtesy to your child if they need extra care.
The scheduled appointment is reserved specifically for your child. Any change in this appointment affects many patients. We understand that there are times that rescheduling an appointment is unavoidable, however, we ask that you kindly do so by calling/texting 48 hours in advance of any scheduled appointment.
Cancelling and/or rescheduling appointments without a 48 hours' notice are subject to a $25 charge per broken appointment.
We reserve the right to NOT schedule any subsequent appointments after two (2) missed or cancelled appointments without a 48-hour notice.
Multiple same day sibling appointments cancelled or rescheduled without a 48-hour notice will result in all future appointments being limited to no more than one (1) family member per date of service.
Parent/Guardian Name:*
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

Clear

Children's Dentistry
John B. Witte D.D.S., P.C.
3035 Matlock Road Arlington, TX 76015
Phone: 817-784-1000
Brush, Floss, Smile!
Financial Policy
Payment Due
The full balance of treatment is due at the time services are rendered.
Self-Pay & Financing Options
We're dedicated to providing options for all our patients, including those who may not have any dental insurance coverage. We offer flexible payment plans and financing options for treatment, and we work with CareCredit to provide additional financing options to our patients. We also accept cash, debit card, and credit card payments. We provide detailed cost estimates before any treatment begins, ensuring that you understand all associated fees and are not surprised by any charges. If you have any questions about insurance coverage, Medicaid, or financing and self-pay options, please call our office. Our team is always available to discuss costs and all of your financial options to ensure you make the best decision for your child's dental care,
Financial Responsibility
The parent or guardian bringing the child to our office and authorizing treatment is legally responsible for payment of all charges. We cannot send statements to other persons.
Statements
If you have a balance on your account, we will send you a statement by text/email with a link to pay. It will show your previous balance, any new charges, and any payments or credits applied to your account.
Past Due Accounts
Unless prior arrangements have been approved in writing by our office, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the due date printed on the statement. A $5.00 late fee may be charged on any account that is not paid within fifteen (15) days of the statement date. Balances that are 60 days old or older will incur a monthly 2% finance charge, which equals an 18% annual rate. Accounts not paid may be subject to collection procedures and additional fees.
Insurance
We are happy to file dental claims for our families who have dental insurance! In general, we will file claims to any company that will pay us directly and does not restrict coverage to a list of participating providers. Filing your insurance is not a guarantee of payment. Please understand that the parent or guardian has the final responsibility for payment of any services rendered. Our doctors recommend treatment based on your child's needs, not on what insurance will pay. Therefore, we will do everything possible to maximize your benefits. Your complete insurance information/card must be presented at the time services are provided and updated as necessary. Most benefits will be verified before your insurance company can be billed. In the event that your insurance has not paid your account within 60 days, the balance may be transferred to your account. We reserve the right to discontinue or refuse to file a claim.
Divorce/Separation
The party responsible for the account prior to the divorce or separation remains responsible for the account. After the divorce or separation, the parent or guardian bringing the child and authorizing treatment will be the person responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from them.
Consent
I have read and understand the above financial policy. I agree to the terms and accept responsibility for any balance not paid by my insurance.
Parent/Guardian Name:*
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

Clear

Children's DentistryJohn B. Witte D.D.S., P.C.3035 Matlock Road Arlington, TX 76015Phone: 817-784-1000Brush, Floss, Smile!
Notice of Privacy Practices
This notice describes how medical information about your child may be used and disclosed, and how you can get access to this information. Please review it carefully.
Your Rights
- Get a copy of your child's dental and medical record.
- Ask us to correct your child's record if you think it is incorrect or incomplete.
- Request confidential communications.
- Ask us to limit what we use or share (though we may not be able to agree).
- Get a list of those with whom we've shared your child's information.
- Get a copy of this privacy notice.
- Choose someone to act for your child if you have given them medical power of attorney.
- File a complaint if you feel your privacy rights have been violated.
Your Choices
- Share information with family, close friends, or others involved in your child's care.
- Provide appointment reminders.
- Communicate for disaster relief situations.
- Contact you for fundraising efforts (you can opt out).
Our Uses and Disclosures
- Treat your child and share information with other professionals who are treating your child.
- Run our dental practice and improve your child's care.
- Bill for services and communicate with insurance providers.
- Help with public health and safety issues.
- Comply with the law.
- Respond to organ and tissue donation requests.
- Work with medical examiner, coroner, or funeral director.
- Address workers' compensation, law enforcement, or other government requests.
- Respond to lawsuits and legal actions.
Our Responsibilities
- We are required by law to maintain the privacy and security of your child's protected health information.
- We will notify you promptly if a breach occurs that may compromise the privacy or security of your child's information.
- We must follow the duties and privacy practices described in this notice.
- We will not use or share your information other than as described here unless you give written permission.
For questions or complaints, please contact our office at the number above.
Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices for Children's Dentistry - John B. Witte D.D.S., P.C.
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

New Patient Registration

Patient Information

Parent Information

Emergency Contact

Dental Insurance Information

Primary

Secondary

Accompanying Your Child

Referral Information

Consent & Authorization

Appointment Policy

Financial Policy

Payment Due

Self-Pay & Financing Options

Financial Responsibility

Statements

Past Due Accounts

Insurance

Divorce/Separation

Consent

Children's DentistryJohn B. Witte D.D.S., P.C.3035 Matlock Road Arlington, TX 76015Phone: 817-784-1000Brush, Floss, Smile!

Notice of Privacy Practices

Your Rights

Your Choices

Our Uses and Disclosures

Our Responsibilities

Acknowledgment of Receipt of Notice of Privacy Practices