Patient registration

Patient Registration

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex:

Ethnicity:

Any Dental Concerns or any additional information we should be aware of?

Address

City

Zip

Preferred Phone #

Email:

Patients live with

The person who brings the child is the responsible party for consent of treatment and payments

Previous Dentist

Has patient been to a dentist in the past?

Dentist Name

Phone Number

Address

Were any X-rays taken?

Date of last cleaning/Fluoride Treatment

Guardian Information

Name

Relationship to patient

Soc.Sec. #

Birth date

Address

Phone

Employer

Employer Address

Additional Guardian Information

Name

Relationship to patient

Soc.Sec. #

Birth date

Address

Phone

Employer

Employer Address

Emergency Contact:

Dental Insurance

MEDICAID: Certificate #

PRIMARY

Subscriber Name

Subscriber D.O.B.

Subscriber Soc. Sec. #

Subscriber ID#

Group Name

Group #

Insurance Company Name

Insurance Company Phone #

Insurance Company Address

SECONDARY

Subscriber Name

Subscriber D.O.B.

Subscriber Soc. Sec. #

Subscriber ID#

Group Name

Group #

Insurance Company Name

Insurance Company Phone #

Insurance Company Address

Whom can we thank for referring you to our practice?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Patients

Patient Name

Birth Date

Nickname/Preferred to be called

Social Security #

Sex

Ethnicity

Any Dental Concerns or any additional information we should be aware of?

Additional Notes

MEDICAL-DENTAL HISTORY

Today’s Date

Child’s Name

Sex

Birth Date

Place of Birth

Date of last medical examination

Child’s Physician/pediatrician

Telephone

Physician’s Address

PLEASE EXPLAIN ANY “YES” ANSWERS IN THE MARGINS

MEDICAL HISTORY

GROWTH AND DEVELOPMENT

Any learning, behavioral, excessive nervousness, or communication problems? (If yes, indicate below)

Diagnosis: ADD/ADHD, Autism Spectrum, Bipolar Dev. Delay, OCD/ODD, PTSD, Speech Delay

Has child had psychological counseling or is counseling being considered for the near future?

Were there any complications during pregnancy or was child premature at birth?

Any problems with physical growth?

CENTRAL NERVOUS SYSTEM

Any history of cerebral palsy, seizures, convulsions, fainting, or loss of consciousness?

Any history of injury to the head?

Any sensory disorders (seeing, hearing)?

CARDIOVASCULAR SYSTEM

Any history of congenital heart disease, heart murmur, or heart damage from rheumatic fever?

Has any heart surgery been done or recommended?

Any history of chest pains or high blood pressure?

HEMATOPOIETIC AND LYMPHATIC SYSTEMS

Has your child ever had a blood transfusion or blood product transfusion?

Does your child bruise easily, have frequent nosebleeds, or bleed excessively from small cuts?

Is your child more susceptible to infections than other children?

Is there any history of tender or swollen lymph nodes or glands?

Any history of anemia or sickle cell disease?

RESPIRATORY SYSTEM

Any history of pneumonia, cystic fibrosis, asthma, shortness of breath, or difficulty breathing?

GASTROINTESTINAL SYSTEM

Any history of stomach, intestinal or liver problems?

Any history of hepatitis or jaundice?

Any history of eating disorders, such as anorexia nervosa or bulimia?

Any history of unintentional weight loss?

GENITOURINARY SYSTEM

Any history of urinary tract infections, bladder or kidney problems?

Is the patient pregnant or possibly pregnant?

ENDOCRINE SYSTEM

Any history of diabetes?

Any history of thyroid disorders or other glandular disorders?

SKIN

Any history of skin problems?

Any history of cold sores (herpes) or canker sores (aphthae)?

EXTREMITIES

Any limitations of use of arms or legs?

Any problems with muscle weakness or muscular dystrophy?

Any arthritis, joint bleeding, joint replacements, or other joint problems?

ALLERGIES

Is your child allergic to any medications?

Any other allergies?

Any hay fever, hives, or skin rashes caused by allergies?

MEDICATIONS OR TREATMENTS

Is your child currently taking any medication (prescription or non-prescription)?

If yes.

Medication (s)

Diagnosis

Dosage

Times Per Day

Has your child ever received therapy (x-ray treatments) or is it planned

Has your child ever received chemotherapy or is it planned

HOSPITALIZATIONS

Has your child ever been hospitalized?

Hospital

Date

Reason

IMMUNIZATIONS

Is your child up to date on vaccines and immunizations?

Please fill in any of the following that your child has now, has recently been exposed to, or has had in the past.

Chicken pox (varicella)

Now

Exposed

Past

Earache (otitis)

Now

Exposed

Past

Eye infection (conjunctivitis)

Now

Exposed

Past

German measles or 3-day measles (rubella)

Now

Exposed

Past

Glandular fever or mono (infectious mono)

Now

Exposed

Past

HIV/AIDS

Now

Exposed

Past

HIV/AIDS

Now

Exposed

Past

Lead poisoning

Now

Exposed

Past

Measles (rubella)

Now

Exposed

Past

Mumps (parotitis)

Now

Exposed

Past

Mumps (parotitis)

Now

Exposed

Past

Scarlet Fever (scarlatina)

Now

Exposed

Past

Sore throat (tonsillitis or pharyngitis)

Now

Exposed

Past

Tuberculosis

Now

Exposed

Past

Upper respiratory infection (URI) or common cold Pharyngitis, rhinitis, sinusitis, or tonsillitis)

Now

Exposed

Past

Venereal disease (genital herpes, gonorrhea, Syphilis, or other)

Now

Exposed

Past

DENTAL DISEASE PREVENTION & ORAL HABITS

How often does your child brush?

Times per

Does your child use dental floss?

Does someone assist your child with brushing and cleaning teeth?

Does someone inspect for thoroughness after the procedure?

Does your child use fluoride toothpaste?

Drinking water source

City water supply

Name of city

Private well or other than city

Has a fluoride analysis been done?

Date of analysis

Fluoride content

Does your child fail to eat a well-balanced diet?

If yes, what foods or food groups are not adequate?

Does (or has) your child have (or had) any of these habits beyond one year of age? (If yes, check)

Thumb-sucking

Finger-sucking

Pacifier

Lip biting

Mouth breathing

Nail biting

Teeth grinding

Other

Does (or has) your child have (or had) difficulty opening his or her mouth, or does the child’s jaw sometimes lock or stick in a certain position?

Does (or has) your child have (or had) popping or clicking noises or pain during chewing or yawning?

Does (or has) your child have (or had) frequent headaches or pain in or about the ears, eyes, or cheeks?

DENTAL HISTORY (New Patients ONLY)

Has your child ever had a fluoride treatment?

Has your child ever taken a fluoride supplement or vitamins with fluoride?

Does your child have a toothache or other immediate dental problems?

Has your child ever had a toothache?

Has your child had any injury to the mouth, teeth, or jaws (fall, blow, etc.)?

Is this your child’s first dental visit?

If no:

Date

Dentist

Reason

Has your child ever had an unfavorable dental experience?

Is (was) your child nourished by nursing beyond age one?

If yes, check

Breast

Nursing Bottle

Both

and to what age?

Date

Signature (Parent or guardian)

APPOINTMENT AND FINANCIAL POLICY

We are pleased to welcome your family to Hendricks Pediatric Dentistry! Our desire is to provide our patients with the highest quality dental care in a trusting, safe, and enjoyable environment. It is our policy to make definite financial arrangements with you before any treatment is initiated. Below is an explanation of our payment procedures. If you have any questions, please do not hesitate to ask.

Please be on time. If you cannot make your scheduled appointment or if you are more than 10 minutes late, and do not call in advance to reschedule or cancel your appointment then your appointment will be considered as a “Broken Appointment”. Following a broken appointment, a letter will be mailed informing you of the missed appointment. If two appointments are broken in a calendar year a dismissal letter will be issued. If the appointment scheduled was for a new patient exam, we will not be able to reschedule that child as a patient. Extenuating circumstances will be considered at the discretion of Dr. Dan
We reserve the right to charge a fee for any missed appointment and/or dismiss the patient from our practice.
If a patient is dismissed from our practice, we will provide appropriate accommodations or emergency care for a period of 30 days following the delivery of the dismissal letter.
Always bring the patient's insurance card.
Please notify us of any changes of address, phone numbers, and insurance coverage as soon as possible.
Payment for services is due at the time services are rendered. We accept cash, check, and credit cards. There will be a $30.00 service charge for all returned checks.
For new emergency visits we require payment in full at the time of the appointment.
As a courtesy, we will provide you with a copy of the charges to submit to your insurance carrier for your reimbursement or you may assign the payment to our office, and we will file the insurance for you.
Our office will file your insurance claim a maximum of two times per appointment.
If the claim is not paid by your insurance carrier within 60 days, you will be responsible for the full balance and further insurance appeal becomes your responsibility. We will be happy to provide you with a claim form so that you can follow up on your insurance claims personally.
You must provide the office with a dental insurance card with the proper mailing address of the insurance company, or provide a dental claim form, which is provided by the employer. If one of these documents is not available at the time of the appointment, you will be responsible for payment of all fees, and we will provide you with a claim form for you to submit for reimbursement.
If insurance benefits are assigned to the doctor, you will be responsible for paying your deductible and copayments at the time of service. However, if your insurance company does not assign benefits to the doctor, your payment in full is expected at the time of service. You are responsible for paying all charges not covered by your insurance company, including all feels considered above your insurance company’s usual and customary fee schedule. Your insurance benefits are a contract between you and your employer. The amount of coverage you will receive will depend on the quality of the plan purchased by your employer, not the fees of the doctor.
The office cannot carry balances longer than 90 days even if the insurance payment is still pending. We reserve the right to charge billing fees and/or employ a collection service to collect payment on accounts with balances greater than 90 days. If your account is delinquent, we will not be able to reserve appointment times (other than emergencies) until your account is current.
The parent or guardian who brings the child for their initial visit is responsible for payment independent of what a divorce decree or custody arrangement may state. Reimbursement must be made between the parents. We will not intervene.

AUTHORIZATION

I have read & accept the above policies. I understand & agree to the terms set forth regarding payment. I understand that the above policies apply to all individuals under my account.

Patient(s) Name(s)

Date

Relationship to Patient(s)

Printed Name of guardian

Signature of Guardian

OFFICE PROCEDURES REGARDING PATIENT WITH TREATMENT AND CONSENT

Our goal in treating your child is to provide the highest quality care utilizing the most up-to-date techniques and materials in a safe, friendly environment by our experienced, caring, and well trained staff. Through our proactive and preventative approach, we work as a team with each patient to achieve great oral health and “cavity free” visits!

Despite our best efforts, there are times when treatment will be needed. Treatment recommendations are based upon clinical and radiographic exams and are supported by the American Academy of Pediatric Dentistry’s Clinical Practice Guidelines and Best Practice Recommendations. Proposed treatment will be discussed with the parent/guardian and a written treatment plan will be provided to review and consent to the agreed upon procedures..

TREATMENT PROTOCOLS

It is our mission to provide an ethical, comprehensive, and welcoming dental home for our patients. If treatment is required, we strive to provide the best, individualized dental care in a calm and comfortable manner. Each patient who visits our office will receive our upmost attention and will be treated as one of our own children. In addition to addressing dental decay, another essential component of our office is oral health education. We strive to be proactive in our office to inspire exceptional oral health. By emphasizing oral health education and building rapport with our patients we believe we can cultivate a generation of children with healthy smiles and a lifelong trust of the dentist.

To facilitate a calm environment and comfortable treatment, Nitrous Oxide is often used. Nitrous Oxide is a very safe and effective inhalational agent. It has many advantages including high patient acceptance, suitable for all ages, non-allergenic, diminished gag reflex, slight analgesic effect, rapid onset, and a fast recovery. If you have any questions or concerns with the use of Nitrous Oxide, please inform Dr. Dan.

As a parent, our children and their safety are our top priority. To provide the best experience for our patients when treatment is needed, we allow parents to accompany their child in the treatment room. We are aware that your child will always “choose” you when uncomfortable situations arise, such as undergoing dental treatment, if they are nervous. Therefore, we ask that if you choose to accompany your child in the treatment room you act as a “silent observer.” Your presence will provide comfort to your child, but it is important that there be an uninterrupted line of communication between Dr. Dan and the patient. This open communication between your child and Dr. Dan will instill trust in the dentist and will boost your child’s confidence and ability to address and conquer challenging situations. If being a “silent observer” becomes too difficult and causes an interference in providing the highest level of care, you may be asked to wait in the reception area until treatment is completed. Additionally, if at any point during the procedure you feel uneasy you are welcome to exit the treatment room and wait in the reception area and our staff will accompany your child to you once the treatment is completed.

Operative treatments are only scheduled in the A.M. as children are more attentive and receptive at this time of day.

CONSENT

Your child is a minor; therefore, it is necessary to obtain signed consent from a parent or guardian prior to any necessary dental treatment. THE PARENT OR GUARDIAN WHO BRINGS THE CHILD FOR DENTAL TREATMENT IS RESPONSIBLE FOR ALL FEES. We will be glad to provide necessary receipts for reimbursement if another party is responsible for the child’s healthcare costs.

I grant the doctor permission to provide my child's dental exam and treatment, including radiographs, study models, photographs, and/or any other diagnostic aid deemed necessary to make a thorough diagnosis, and perform any treatment or therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I will be responsible for all costs associated with this dental care. I authorize Hendricks Pediatric Dentistry to send a dental report to my child's physician, and/or referring dentist. I authorize the release of any medical information necessary to process insurance claims, and I also request payment of benefits to the dentist. However, if I pay in full at time of service, insurance benefits will be paid directly to me. If it would be necessary to involve a third party to collect all or any part of an amount owed to Daniel Allen, DMD, MSD, LLC d/b/a Hendricks Pediatric Dentistry, they are entitled to the cost of collection. I acknowledge that the above policy has been explained to me along with the recommended treatment, and that my questions have been answered to my satisfaction. Also, by signing this document I acknowledge that I have been offered a copy of this office's Notice of Privacy Practices. You may refuse to sign this acknowledgement. However, we will not be able to file insurance and payment in full will be due at time of service. Please understand that revocation will not affect any action we took prior to this consent, and that we may decline patient treatment if you revoke this consent.

Patient(s) Name(s)

Date

Relationship to Patient(s)

Printed Name of guardian

Signature of Guardian

HENDRICKS PEDIATRIC DENTISTRY DANIEL ALLEN, D.M.D., M.S.D.

Patient/Guardian Authorization to Disclose Protected Health
Information to Others and Consent to Treat

Patient Name

Birthdate

Patient Name

Birthdate

Patient Name

Birthdate

Patient Name

Birthdate

Patient Name

Birthdate

Patient Name

Birthdate

I give permission for protected health information to be disclosed to the following person(s). They may also consent to treatment for the above named patients. This includes scheduling appointments, bringing them to appointments, signing treatment consents and approving use of Nitrous Oxide (laughing gas).

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Printed name of legal guardian

I hereby declare that I am the legal guardian of above named patient(s).

Signature of legal guardian

Relationship

Date

Please provide any legal documentation showing assignment of relationship to patient(s).

Note: If at any time you want to update this information it is your responsibility to ask for a new form. The most current form will be honored.