Arkansas Pediatric Dentistry NEW

Patient Informaton

Dr. Cara Jones DDS
Name*

First NameMiddle NameLast Name
Gender*

MaleFemaleOther
Is anyone in your family a current patient?*

YesNo
What's their name?
SSN#*
Birth Date:*
Phone (Home):*

Area CodePhone Number
Phone (Cell):

Area CodePhone Number
Phone (Work):

Area CodePhone Number
E-mail*
Preferred Method of Contact:

Text MessageE-MailPhone Call
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
Whom may we thank for referring you to our practice?

PatientRelativeFriendDental OfficeYellow PagesInternetSchoolWork
Name of person or office referring you to our practice:
Health Information
Date of Last Dental Visit

MonthDayYear
Reason for today's visit
Have you ever had any of the following? Please check those that apply*

AIDS/HIV+AnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersMirtral Valve ProlapseNervous DisordersPacemakerPregnantRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseNone of the Above
Do you have any allergies?

YesNo
Please list your allergies here:
Are you currently on any medications? *

YesNo
Please list your current mediations:
Have you ever had any complications following dental treatment?*

YesNo
If yes, please describe your dental complications.
Have you been admitted to the hospital or needed emergency care during the past two years?*

YesNo
If yes, please descibe your hospital stay.
Is this Child up to date on all current vaccinations?*

YesNo
Is no, please list what vaccinations are currently missing.
Are you now under the care of a physician?*

YesNo
Is yes, please describe your current care.
Name of physician:
Phone Number:
Do you have any health problems that need further clarification?*

YesNo
Please explain.
Please tell us what about your smile you would like to approve upon
Insurance Information
Does the patient have dental insurance?*

YesNo
Would you be interested in financing options?

YesNo
Name of Insurance Company
Name of Insured

First NameMiddle NameLast Name
Insured's Date of Birth

MonthDayYear
ID #
Group #
If you are on a smartphone or tablet and can take a photo of your insurance card, please do so now. If not please ignore this box.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer Name
Patient's Relationship to insured:

SelfSpouseChildOther
Parent or Guardian Information
Please Select

FatherStep-FatherGuardian
Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
SSN#
Insured's Employer Name
Patient's relationship to insured

SelfSpouseChildOther
Please Select

MotherStep-MotherGuardian
Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
SSN#
DL#
Insured's Employer Name
Patient's relationship to insured

SelfSpouseChildOther
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends on reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that a reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suited be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

I have read the above conditions of treatment and payment and agree to their content.
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with the office late fee, as well as current office procedures as outlined in the above text.*
Date*

MonthDayYear
Relationship to Patient
Arkansas Pediatric Dentistry HIPAA Consent Form

Dr. Cara Jones DDS
THIS NOTICE DESCRIBES TO WHOM MEDICAL INFORMATION ABOUT YOU MAY
BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
________________________________________________________________

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides
privacy protections to your medical records. Our benefits office (or other third party
designated by our office) may sometimes need to disclose medical information or
payment information protected by HIPAA in relation to our group health plans to your
family members or close friends involved in your health care. For example, your spouse
may need to contact us if you are in the hospital to determine whether a particular
procedure is covered under our group health plan or may need assistance filing a claim
for medical services. Under HIPAA, unless you specifically object we are allowed to use
our professional judgment in deciding whether to discuss you medical and payment
information with you family members or close friends. However, we would like to provide
you with the opportunity to tell us with whom we may discuss your medical or payment
information under our group health plans.
Arkansas Pediatric Dentistry may communicate with the following individuals for relating to my medical or payment information:*
Please type each name
Arkansas Pediatric Dentistry may NOT communicate with the following person(s)
Please type each name
COMPLAINTS
If you think that we have not properly respected the privacy of your health
information, you are free to complain to us or the U.S. Department of Health and Human
Services, Office for Civil Rights. We will not retaliate against you if you make a
complaint. If you want to complain to us, send a written complaint to the office contact
person at the address, fax or E mail shown at the beginning of this Notice. If you prefer,
you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office
contact person at the address or phone number shown at the beginning of this Notice.
Arkansas Pediatric Dentistry Office Policy

Dr. Cara Jones DDS PLLC
Arkansas Pediatric Dentistry Dentistry Appointment Policy

Need to reschedule an appointment? Let us know in advance!

We value your time!
Our goal is to provide our patients with beautiful, healthy smiles—and then get them on their
way!

We know you don't need added stress in your life. We want to reduce unnecessary chaos and
get you in and out as efficiently as possible, so you can get back to your already busy schedule.
But we need your help!

Need to cancel?
WE HAVE MADE SOME POLICY CHANGES TO THIS PORTION, PLEASE READ THROUGHLY.

We require 48 hours' notice ahead of time. If you cancel your child's appointment with less than 48 hours notice, you will be charged a fee of $25 per child before you are able to reschedule the appointment.

Otherwise, if you cancel more than twice with less than 48 hours' notice OR skip your
appointment without any prior notice, we will not schedule your family back at Arkansas Pediatric Dentistry unless it's an emergency.

This policy isn't in place to be cruel. It's to be fair to all of our groovy patients! Giving us advance notice when you need to cancel allows us to help another family who may need our care during that time.

Help us keep our office chompy!
At your appointment:
- Please arrive 20 minutes early for your new patient visit and 5 – 10 minutes early to
  each subsequent appointment.
- Understand that if you arrive more than 10 minutes late, we will do our best to see you,
  but you may need to reschedule. If you are late to a sedation appointment, you will not
  be able to be seen for that appointment and will be required to reschedule
- Call our office immediately if you anticipate being late.
- Remember only one parent can accompany your child back to the treatment area**.
Thank you in advance!
We truly appreciate your cooperation. Thank you for respecting everyone's time, and we
promise to do the same for you! If you have any questions, please contact our office. We look
forward to seeing you soon!
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Relationship to patient
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with Arkansas Pediatric Dentistry HIPAA Consent form, Office policy and all information held therein.*
Should be Empty:

Patient Informaton

Referral Information

Health Information

Insurance Information

Parent or Guardian Information

Arkansas Pediatric Dentistry HIPAA Consent Form

Arkansas Pediatric Dentistry Office Policy