New Patient Form

New Patient Form
1. Tell us about your child.
Name*

First NameLast Name
Preferred Name
Gender

MaleFemaleNot Listed
Age
Date of Birth*

MonthDayYear
Date
Interests/Hobbies/Pets
School
Grade
Name(s) and Age(s) of Sibling(s)
How did you hear about our office?*

Electronic Communications
5. Electronic Communications
I understand the confidentiality of electronic communications (e-mail, text, etc.) cannot be guaranteed and Southern Smiles Pediatric Dentistry is not responsible for the confidentiality or security of any message sent to or by me. If any of my contact information changes or at any time I wish to terminate this consent, I agree to notify Southern Smiles Pediatric Dentistry in writing or in person.
I authorize Southern Smiles Pediatric Dentistry to contact me via electronic media.I do not authorize Southern Smiles Pediatric Dentistry to contact me via electronic media

Dental Insurance Information

(If Applicable)
Dental Insurance Information (If Applicable)
Do you have dental insurance?*

YesNo
Primary Insurance
Person Who Carries Insurance

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Member ID #
SS #
Employer
Insurance Company Name
Phone Number
Please enter a valid phone number.
Group #
Policy #
Secondary Insurance
Person Who Carries Insurance

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Member ID #
SS #
Employer
Insurance Company Name
Phone Number
Please enter a valid phone number.
Group #
Policy #
I certify that my dependent(s) is covered by insurance with company Insurance Company Name and I assign all insurance benefits to be paid directly to Southern Smiles Pediatric Dentistry, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Southern Smiles Pediatric Dentistry may use and disclose my child’s health care information to the above-named insurance company and their agents for the purpose of obtaining payment of services and determining benefits or the benefits for related services. This assignment will remain in effect until I cancel it in writing.

Consent for Dental Treatment
I am the parent, guardian, or personal representative of the above named patient and there are no court orders now in effect that prevent me from signing this consent. I do hereby request and authorize the attending doctor and team to perform any necessary dental services including but not limited to preventive care, radiographs and photographs as necessary for diagnostic purposes; I understand that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. The dental team provides an environment that will help my child learn to cooperate during treatment including praise, explanations, demonstrations of procedures and instruments, and using variable voice tones. Initial*
Financial Agreement
Please familiarize yourself with the following information regarding financial obligations. If you have any questions regarding our financial policy, please ask our administrative team for assistance.

Payment in full is due when services are rendered. Payments may be made by the following options:
- We accept Cash, Money Orders, MasterCard, Visa, American Express and Discover. We do not accept personal checks.
- We are a participating provider for CareCredit which allows you to pay your financial responsibility at the time of service. You may be eligible for a 6 month/deferred interest plan. Please ask our administrative team for more information or visit www.carecredit.com for details.
- We also accept dental insurance and as a courtesy, will file the insurance on your behalf. Please contact your insurance company for verification of dental benefits and plan restrictions. Some insurance companies recommend a pre-treatment authorization for the dental treatment to be provided and fees to be incurred prior to determining their benefits to you. We will attempt to estimate any out-of-pocket expenses prior to your visit to our office. Please be prepared for any deductible, co-pay, or other expenses at the time of service. If, for any reason, your insurance company does not respond with financial payment within 45 days post treatment, the balance is due and payable in full immediately by the parent/legal guardian financially responsible. Overdue balances are susceptible to finance charges.
The parent/legal guardian is responsible for payment of all patient accounts. We do not intervene in custody and/or financial disputes which may or may not involve court orders.

I have read and understand the financial policies of Southern Smiles Pediatric Dentistry. In the event of default payment, I promise to pay any legal interest on the balance due, together with any collection costs. Collection fees will equal 50% of the amount referred for collection. Reasonable attorney fees incurred to effect collection of the account or future outstanding accounts will be the responsibility of the parent/legal guardian. Signature*
Appointment Agreement
Southern Smiles Pediatric Dentistry reserves a specific time for your child according to their treatment needs and level of cooperation. We make every effort to see your child at their appointed time. Inadvertent delays, such as emergencies and unforeseen patient treatment difficulties, may arise causing schedule changes. Should your child’s appointment time be delayed, please accept our apology.

We ask that you arrive 5 to 10 minutes prior to your child’s scheduled appointment. This will allow time to complete any necessary paperwork. Parents that are running late are asked to call the office as soon as possible. In consideration of other patients, your child’s appointment may be rescheduled if you are late for your scheduled time.

School holidays, as well as after school hours, are our most popular appointment times. Missed or cancelled appointments with less than a 2-business days’ notice that are scheduled on a school holiday or after school will not be rescheduled to another school holiday or after school hours.   Initial*

Appointments must be confirmed. As a courtesy, our office will attempt to contact you to confirm your child's visit; however, we ask that you assume responsibility for your child's appointed time and confirm either by phone, text or email. Please note, if confirmation is not received with 1-business day of the appointment, your appointment will be released to accommodate another patient. If the appointment is cancelled or broken with less than 1-business day notice, a fee may be charged to your account. Initial*

We require a 2-business day notice to change restorative appointments. If the mandatory notice is not given, prepayment for treatment will be collected prior to the appointment being rescheduled and a fee may apply.      Initial*
Parent / Legal Guardian Name*

First NameLast Name
Relationship to Patient*
Date*

MonthDayYear
Date
Parent / Legal Guardian Signature*

Clear

Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse to Sign This Acknowledgement *
Acknowledgement of Receipt of Notice of Privacy Practices
Southern Smiles Pediatric Dentistry’s Notice of Privacy Practices is available for review and I am aware that I am entitled to a copy upon request.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

New Patient Form

1. Tell us about your child.

Parent/Guardian Information

2. Parent/Guardian Information

3. Parent/Guardian Information

4. Parental Status

Electronic Communications

5. Electronic Communications

Dental Insurance Information

Dental Insurance Information (If Applicable)

Primary Insurance

Secondary Insurance

Dental History

Dental History

Does your child have any of the following habits?

Medical History

Medical History

Consent for Dental Treatment

Financial Agreement

Appointment Agreement

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices