• New Patient Form, Ages 0 to 4

    Complete this multi-page intake for your child and provide required details for consent, emergency contact, and health history.
  • Has your child had or does your child have any of the following?

  • Page 1 · Child and family

  • Welcome! Please fill out this form for your child. A parent or guardian should complete and sign it. If a question doesn't apply, just leave it blank.
  • This form is a:*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • The child lives with
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred contact

  • Page 2 · Consent, emergency contact and referral

  • Who may give consent for this child's dental care? (check all that apply)*
  • Is there a custody arrangement or court order about this child's care that we should know about?*

  • Child's doctors

  • Format: (000) 000-0000.
  • Other specialists who see your child (for example, ear, nose and throat doctor, therapist, or other specialist):
  • Format: (000) 000-0000.
  • How did you hear about us? (check all that apply)

  • Page 3 · Pregnancy, birth, feeding and health history

  • Your child was born*
  • Type of delivery*
  • Were there any complications during pregnancy or birth?*
  • Did your child stay in the NICU?*
  • Milk feeding*
  • Reflux
  • Frequent ear infections
  • Frequent colds or congestion (stuffy nose)
  • Snoring or noisy breathing
  • Mouth breathing
  • Sleep concerns
  • Developmental concerns
  • Therapies, now or in the past (occupational, physical or speech therapy)
  • Solids started?*
  • Has your child had any feeding difficulties?*
  • Has your child been seen by a lactation or infant feeding specialist?*
  • Taking any prescription or daily over-the-counter medicines?*
  • Hospital stays or surgeries
  • Medical conditions or diagnoses

  • Page 4 · Allergies, medications and dental

  • Is your child allergic to or has your child ever had any reaction to the following? (Check all that apply)*
  • Is your child currently taking any of the following? (Check all that apply)
  • Medication list

  • Dental insurance

  • Do you have dental insurance?*

  • Primary insurance

  • Subscriber date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Patient relationship to subscriber*
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  • Do you have secondary dental insurance?

  • Secondary insurance

  • Subscriber date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Patient relationship to subscriber*

  • Financial guidelines

  • Financial Guidelines We are committed to providing you with the best care possible to achieve total health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines. INSURANCE We accept all major dental insurance payments, however we may not be an in-network provider for your plan. If we are not an in-network provider, review your plan details, as in many cases insurance reimbursement is very similar. • We will assist our patients in filing insurance claims through any benefit company that allows your choice of provider. As part of our legal agreements, the dental insurance plan administrators require that we offer no additional discounts and collect co-payment at the time of service. • We also offer our SmileSavers discounted health care services plan for our patients that do not have a dental benefit plan. • No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. PAYMENTS Patient portion or patient co-payment is due at the time services are rendered – unless prior financial arrangements have been made. • Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. • All major credit cards are accepted (Visa, MasterCard, Discover). • 3% discount for our uninsured patients who pay by cash/check. • Various financing options with CareCredit®. SHORT-NOTICE CANCELED/MISSED APPOINTMENTS • Please give a minimum 48 hour notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments and we appreciate the same courtesy from you. • Late, canceled or missed appointments may be subject to a fee of $75 for every 15 minutes of time reserved, or $50 for a hygiene appointment. If you are late, cancel or miss more than two appointments without notice in a 6-month period, you will be required to place a deposit in order to secure your appointment time.
  • By checking this box, I acknowledge I have read and understand the guidelines above.*
  • Signature*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Privacy and communication

  • Acknowledgment of Privacy Practices My signature confirms that I have been informed of my rights to privacy regarding my protected personal and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand the terms in which my personal health and identification information may be used. I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
  • Signature*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Relationship to patient*
  • Please list any dependent children under the age of 18 also covered by this acknowledgment
    Rows
  • In addition to the entities mentioned in the Notice of Privacy Practices, I authorize Synergy Dental Solutions to release my health information to the following individuals:
    Rows
  • I give permission for the following communications to be used by Dr. Angela Tenholder, DMD (check all that apply):
  • I am granting permission for Angela Tenholder, DMD to disclose their identity to anyone who may answer my home, work or cell phone.*
  • I am granting permission for Angela Tenholder, DMD to leave a message with any person who may answer my phone or on my voicemail of the following numbers (check all that apply):
  • I would like to give permission for the following person(s) to have access to personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above:
    Rows

  • Patient consent and payment authorization

  • Patient Consent – Payment Authorization – Signature on File To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medication changes, I shall inform the dentist and staff at the next appointment without fail. I hereby authorize payment directly to Dr. Angela Tenholder of the dental benefits otherwise payable to me. I hereby authorize Dr. Tenholder to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. By signing below, I acknowledge that I have read and understand the statements mentioned above.
  • Relationship to patient*
  • Signature*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please also complete our Patient Photo Release: https://form.jotform.com/262775948196073
  • Should be Empty: