Sutton - New Patient Forms (Family) w/ upload

Additonal Contact
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Financial Responsibility
Who is financially responsible for this account?*
Address (if different than above)
Home phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Dental Insurance
Primary policy holder's full name*
DOB*
Social Security #*
Relationship to patient*
Address and phone (if not listed above)
Employer*
Insurance Company*
ID #*
Group #*
Secondary Policy holder's full name
DOB
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance Company
ID #
Group #
Photo of Dental Insurance (Front)

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Cancelof
Photo of Dental Insurance (Back)

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Cancelof
Medical Insurance
Policy holder's full name
Insurance Company
Photo of Medical Insurance (Front)

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Cancelof
Photo of Medical Insurance (Back)

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Cancelof
Physician
Primary Care Physician*
City, State*
Phone Number*

Area CodePhone Number
Fax number*

Area CodePhone Number

Release and Wavier
I authorize release of any information regarding my child’s dental treatment to my dental and/or medical insurance company.

I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my dentist/staff of any changes in my child’s medical or dental health.

To improve communications with our patients, Sutton Children's Dentistry & Orthodontics will be emailing and/or texting appointment reminders. If you are interested in being part of this service, please enter your information below. Please be aware that this email address may also be used to email you personal information (i.e.. Receipts, Invoices, Letters) relating to your dental care. Your information is only used for communications with you and other dental professionals. We do NOT share or sell personal information.

I hereby authorize the dentists and staff at Sutton Children's Dentistry & Orthodontics to perform diagnostic aids including an examination, x-rays, photographs, models, cleaning and fluoride treatment, when necessary, as the standard of care to properly diagnose and record any and all dental conditions. I authorize my insurance company to pay Sutton Children's Dentistry & Orthodontics all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, all broken appointment fees and all late payment services charges. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Sutton Children's Dentistry & Orthodontics's. This consent is to remain in effect from the date indicated until canceled in writing.
Parent/Guardian Signature*

Clear
Date

General Consent
I attest that the information I have provided on this form is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I understand that by signing below I authorize the following procedures to be performed as deemed necessary by the dentist and have read and understand the possible risks and complications of each procedure.

X-Rays & Examination

I understand that my child will be receiving a dental examination from a state licensed pediatric dentist. I understand that x-rays may be taken of my child's teeth as part of the necessary requirements to complete a thorough and comprehensive examination.

Medical Photography Consent

I consent to digital photographs and x-ray images of my child to be used exclusively within their medical record for the purposes of identification and dental treatment. Dental Cleaning and Fluoride Treatment I authorize Dr. Paquin/Dr. Kiang/Dr. Edwards and/or his staff members to clean my child's teeth today. I understand that the application of fluoride is part of the standard of care for children and helps prevents cavities.

Dental Sealants and Restorations

I authorize Dr. Paquin/Dr. Kiang/Dr. Edwards and/or their staff members to perform sealants and restorations including composite fillings, amalgam fillings, stainless steel crowns and space maintainers as part of comprehensive dental care. Any invasive procedures will obtain a separate consent.

Drugs and Medication

I understand that antibiotics, analgesics and topical compounds can cause allergic reactions even with no prior known history. Allergic reactions can cause redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock. I
have informed the dentist, to the best of my knowledge, of any adverse reactions my child has had.

I understand that all the above treatments are the standard of care in pediatric dentistry. It is my responsibility to inform the staff during the registration process if I choose to decline any of the above treatments.

Authorization and Release

I authorize Dr. Paquin/ Dr. Kiang/Dr. Edwards and/or their staff to release any information including the diagnosis and the records of any treatment or exam rendered to my child during the period of such dental care to third party payors, health practitioners and as required by law.
Parent/Guardian Signature*

Clear
Date

HIPPA Acknowledgement
The department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your
health care information and information about treatment, payment or health care operations, in order to provide healthcare that is in your best interest.

We also want you to know that we support your full access to your personal dental records. We may have indirect treatment relationships with you (such as laboratories that only interact with doctors and not patients) and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat should you choose to refuse to disclose your Personal Health
Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all of part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with your HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper
disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.

We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity.
More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may useand/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to
sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
Email
example@example.com
Name*

First NameLast Name
Signature*

Clear
Date
FOR OFFICE USE ONLY

The patient refused to sign.Due to an emergency situation, it was not possible to obtain an acknowledgement.We were not able to communicate with the patient.Other
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