New Patient Registration

New Patient Registration
Child's Complete Name
Child's Nickname
Sex
Birthdate

MonthDayYear
Date
Home Number
Cell Number
Parent’s/Guardian’s #1 Name
Relationship to Patient
Occupation
Employer
SSN
Cell Number
Email Address
Parent’s/Guardian’s #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's/Guardian's #2 Name
Relationship to Patient
Occupation
Employer
SSN
Cell Number
Email Address
Parent's/Guardian's #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Names and ages of siblings
Does your child have dental insurance?

YesNo
Secondary Insurance?

YesNo
Insurance #1
Name of Policy Holder
SSN or Insurance ID #
Name of Insurance Co.
Group or Policy #
Insurance #2
Name of Policy Holder
SSN or Insurance ID #
Name of Insurance Co.
Group or Policy #
Whom may we thank for referring you to our office?
I hereby authorize direct payment (of the group insurance benefits OTHERWISE payable to me) to Dr. Shahram Fazilat, D.D.S
Signature of Insurance Policy Holder #1

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Signature of Insurance Policy Holder #2

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Medical History
Is your child in good health?

YesNo
Is your child under a physicians care? For what?

YesNo
Does your child have any history of major illnesses? What and when?

YesNo
Has your Child ever been hospitalized? For what?

YesNo
Is your child taking any medications/drugs presently? What?

YesNo
Does your child have any allergies or drug sensitivities (including to penicillin & local anesthetic)?

YesNo
Allergic to latex?

YesNo
Have tonsils and/or adenoids been removed?

YesNo
What age?
Are there any learning disabilities? If yes, please explain

YesNo
Check any of the following conditions for which the patient has a history of:

CancerSeizuresLiver / Kidney DiseaseArthritisEmotional ProblemsNutritional ProblemsAsthmaBlood DisordersFainting / DizzinessRheumatic FeverBone DisordersHeart TroubleSpeech / Hearing ProblemsCerebral PalsyHepatitisTonsillitisDiabetesHIV / AIDSTuberculosis
Any other signification medical, psychological, or disability problems, please describe?
Dental History
Is this your child’s first visit to the dentist?

YesNo
Any history of injuries to the face, mouth or teeth?

YesNo
What?
Does your child have a toothache or any otherimmediate dental problems?

YesNo
If yes, please explain
Any history if mouth habits (sucked thumb, pacifier,nail biting, grinding)? Until what age?

YesNo
Does your child have any history of cavities, tooth / guminfections, missing or extra teeth?

YesNo
If yes, please explain
Does your child see the dentist regularly? Date last seenand for what?

YesNo
Date last seen and for what?
Has any previous dental treatment been attempted /completed?

YesNo
What?
Were there any problems with previous dental treatment?

YesNo
If yes, what were they?
Are supplemental fluorides used?

YesNo
If yes, what ( drops, tablets, rinses )
Do you use tap water for cooking / drinking?

YesNo
How often are the teeth brushed?
Flossed?
By whom?
First tooth erupted at about months
Name of child’s former dentist:
Name of parent’s dentist:
School your child attends:
How would you anticipate your child to behave in our office?
Please name your child’s favorite toy, movie, hobby:
Every child is a unique individual thus not every child will require the same treatment to obtain a comprehensive oral examination. Based upon your child’s age, teeth present, and tooth position, the dentists at Growing Smiles Pediatric Dentistry will determine if radiographs (x-rays) are necessary. Generally, in addition to the examination we complete a cleaning of the teeth and application of topical fluoride. If your child should need any dental treatment after the dental examination has been completed, the dentist will review the planned treatment with you. I hereby give permission to the dentists and staff at Growing Smiles Pediatric Dentistry to render all necessary dental services and to use such method and agents as they see fit for the child named on this form and to contact the child’s physician as necessary. I understand that no treatment will be started until recommended treatment time involved, and financial investments have been discussed with me by the dentists or one of their staff members, at which time I may void this permission if I so choose. Furthermore, I will be responsible for any bills incurred by this child for dental treatment.
Parent’s / Guardian’s Signature

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Date

MonthDayYear
Date
Notice of Privacy Practices (HIPAA):
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.

As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would include teeth cleaning services.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities and utilization review. An example would be sending a bill for your visit to your insurance company for payment.
- Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analyses,
  and customer services. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health- related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
- The right to reasonable requests restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
- The right to inspect and copy your protected health information.
- The right to receive and accounting of disclosures of protected health information.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of

MonthDayYear
and we are required to abide by the terms of the Notice of Privacy Practices and to make the new notice provisions effective for all protected

health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practice from this office.

I hereby give consent for Growing Smiles Pediatric Dentistry to take photographs of my child/children. I consent to the use of these images to promote the dental practice through various media, including but not limited to print advertising, brochures, and the practice website. If you decline the use of photographs, please initial here
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You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services. Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information.

For More Information about HIPAA or to file a complaint:

The US Department of Health & Human Services Office of Civil Rights 200 Independence Ave., S.W. Washington, D.C. 20201 Toll Free: 1-877-696-6775
Patient’s Name:
Print Legal Guardian’s Name:
Legal Guardian’s Signature

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FINANCIAL POLICY
This statement is to inform you of our financial policy. Financial arrangements are both necessary and beneficial to maintaining a sound professional relationship. We wish to inform you of our office policy in this regard. We are also committed to providing your child with up-to-date information and educational tools so that you may fully participate in maintaining your child’s optimum oral health. Our financial policy is intended to facilitate excellent service to your child while minimizing our administrative costs.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with your child, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a part of that contract. If payment from your insurance company is not received within 60 days from date of service, you will be expected to pay the balance in full.

As a courtesy to you we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our office by signing the authorization on the Assignment of Benefits Agreement. In order for our office to file your insurance claim, you must bring a completed dental insurance form or proof of insurance at each appointment.

Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, and Discover. We offer payment plans through third party financing. If you would like more information regarding to the third party financing please check with our financial coordinator.

Returned checks and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month (18% annually Our office will charge you equivalent to an office visit of $50 per child for missed appointments and appointments cancelled without a 48-hour advance notice. It is vital you give our office a 48-hour notice to avoid cancelled appointment charges. Additionally, please be advised that if you are more than 10 minutes late to your appointment, we may not be able to accommodate you and you may be asked to reschedule. Please arrive on time so that you can ensure that your child is seen at their appropriate appointment time.

If you have any questions regarding our financial policy, please ask. We are committed to providing you with the most positive experience in dental care.
Patient’s Name
Parent’s/Guardian’s Print Name
Parent’s/Guardian’s Signature

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Date

MonthDayYear
Date
Dental Materials Fact Sheet
This is information provided by the dental board of California to advise patients of the types of materials used in the dental office. By signing this form you acknowledge receipt of the fact sheet.

*Please refer to link on Patient Registration Page for a copy of the Dental Materials Fact Sheet*
Please Initial

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Should be Empty:

New Patient Registration

Insurance #1

Insurance #2

Medical History

Dental History

Notice of Privacy Practices (HIPAA):

FINANCIAL POLICY

Dental Materials Fact Sheet