Child New Patient Information

Child New Patient Information

Welcome you to Jeffrey Kwong Orthodontics (JKO)! In an effort to provide the best service possible and to be fully prepared for your questions about insurance and payments, we ask you to fill out this form as completely as possible. Thank you for your help with this. We understand that medical paperwork can be a nuisance! That’s why we want to give you the chance to get it out of the way when it’s convenient for you. If you don't have enough time to fill this out in one sitting, please SAVE your progress, the "Save" button is at the bottom of the form
Patient Information
Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Gender*
Date Of Birth*

MonthDayYear
Date
Age*
School Name & Grade*
If not applicable please type N/A.
What hobbies and interests make them smile?
Responsible Party 1
Responsible Party*

MotherFatherStep ParentOther
Do You Have Dental Insurance*

YesNo
Responsible Party 1's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
Employer Name*
Responsible Party 1's Date of Birth *
Dental Insurance Carrier Name*
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identification number or SSN*
Group Number *
Insurance Company Phone Number *
Please enter a valid phone number.
Do You Have Dual Dental Insurance Coverage*

YesNo
Responsible Party 2
Responsible Party 2

MotherFatherStep ParentNot Applicable (No other responsible party)Other
Responsible Party 2's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Employer Name *
Identification number or SSN
Responsible Party 2's Date of Birth *
Email*
example@example.com
Dental Insurance Carrier Name*
Insurance Company Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identification Number or SS# *
Group Number *
Insurance Company Phone Number*
Please enter a valid phone number.
Other Information
Reason For Consultation, What Would Make For a Successful Treatment For You? *
How Did You First Hear About Our Office?*

One of Our Valued PatientsYour DentistFamily MemberA Fantastic FriendAn Awesome JKO Team MemberGoogle SearchGoogle AdsGoogle ReviewsFacebookInstagramEDH Soccer PartnershipTAZ Swim Team PartnershipOther
Whom May We Thank For Referring You To Our Office?*

Please Tell Us How Important the Following Are To You:*

	Not	Somewhat	Important	Very	Extremely
Length of treatment Time
Comfort of Treatment
Latest Technology
Clear/Invisible
Low Down Payment
Patient Doctor Communication
Interested in starting within the month

Present Dentist *
If you don't have a current Dentist, please type N/A
Estimated Date of Last Cleaning *

MonthDayYear
Date
Other Dental Specialists Seen?
Type of Specialist and Name
Estimated Date Last Seen

MonthDayYear
Date
Name(s) of immediate family members who are/have been seen by Dr. Kwong*
Please enter NA if not applicable
Are you aware that some appointments will need to be in during school hours?*

YesNo
Medical History
Physician's Name:*
Physician;s Phone Number:*
Please enter a valid phone number.
Now or In The Past, Have You Ever Had:

AIDS/HIVAllergiesAnemiaArthritisAspirin RegimenAsthmaAttention Deficit/HyperactivityAutism Spectrum ConditionBone DisordersBulimiaCancerCerebral PalsyChest PainsChronic Neck PainClicking Of JawCold Sores/HerpesDiabetesDown SyndromeDrug AllergiesEndocrine ProblemsEmotional ProblemsEmotional DisordersEpilepsyFainting, dizzinessFinger SuckingGlaucoma
HeadachesHeart ConditionHepatitisHigh Blood PressureImmune ProblemsKidney ProblemsLatex AllergyLow Blood PressureMuscular DisordersNervous DisordersOrgan TransplantPainful ChewingPeriodontal ProblemsPneumoniaProlonged BleedingRheumatic FeverScoliosisSeizuresSleep ApneaSpeech ProblemsThumb SuckingTMJ ProblemsTobacco UseTongue HabitTuberculosisN/A
Please Explain Any "Yes" Answers From Above:*
If not applicable, please type N/A
Any Concerns or Problems Not Mentioned Above?*
If so, please elaborate, if not please answer "No"
Please list any prescription or over-the-counter medications:*
If not applicable, please type N/A
Currently taking or ever taken a Bisphosphonate? Includes any medication used to make bones stronger, such as:*

BonivaActonelFosamarN/AOther
Allergies/Reactions To The Following::

Aspirin, tylenol, ibuprofenCodeine or other NarcoticsLocal AnestheticsPenicillin or other antibioticsSedativesSulfa DrugsBarbiturates
LatexMetalsPlastic or VinylSleeping PillsN/AOther
Have You Now or In The Past:*

Been required to use antibiotics prior to treatment?Have had tonsils and/or adenoids removed?Breath through your mouthHave had injuries to the face, mouth or teeth?Have lost or chipped any teeth?Have your gums bleed when you brush?Have any tension headaches?Have any pain or soreness around your face, neck or back?Have uncomfortable teeth or jaws when you awaken in the morning?Are you aware of clenching your teeth during the day?Have you ever been told that you grind your teeth?You currently wear a nightguardIs any part of your mouth sensitive to temperature or pressure?Have you been told or know that you snore?Have you woken up gasping for air or been told that you stopped breathing when asleep?Have regularly experienced daytime sleepiness?Have you regularly experienced sleep that isn't restful?N/AOther
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my orthodontist of any change in my health and/or medication. Further, I will not hold my orthodontist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Orthodontist Signature and Date Signed
New Patient Acknowledgements
Consent to Examine:

Dr. Kwong has my permission to examine myself/my child's skeletal growth and
dental development. I understand that treatment recommendations will be explained simply and clearly and that I am encouraged to ask question until I fully understand the recommendations. Dr. Kwong has my permission to share records with my dentist or referring specialists as needed. I ;understand the consultation and any necessary photographs and x-rays are provided as a complimentary service.
Consent for Photograph Usage: I provide consent for the photographs of myself/my child to be used in the following ways: ⦁ Internal Uses (In office displays, Photo Frames, Check In, etc) ⦁ External Uses (Social Media, Newsletters, Print Marketing, Educational) ⦁ Fun/Celebratory Purposes ⦁ Clinical Purposes*

YesNo
HIPAA Acknowledgement

I have been provided a copy of the HIPAA Statement for Jeffrey Kwong Orthodontics, I have reviewed and signed it and have no outstanding questions. I provide consent for Jeffrey Kwong Orthodontics to leave a message on all the numbers provided on the intake forms. I understand that texts, emails and phone messages may not meet the HIPPA compliance standards if I elect for their use. I provide permission for Jeffrey Kwong Orthodontics to contact me in the following ways:

⦁ Email
⦁ Text
⦁ Phone
⦁ Traditional Mail

If you want more information about our privacy prctices, or have questions or concerns, please contact Jeffrey Kwong DDS MSD at:

Telephone: (916) 933-0532
Fax: (916) 933-0678
E-mail: info@jkortho.com
Address: 4693 Golden Foothill Pkwy
El Dorado Hills, CA 95762

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.
Acknowledgement of Receipt of Notice of Privacy Practices
**You My Refuse to Sign This Acknowledgement**

I have received and/or have been offered a copy of the Jeffrey Kwong Orthodontics Notice of Privacy Practices.
Patient Legal Name*
Date*

MonthDayYear
Date
Signature*

Clear
*If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name

First NameLast Name
Relationship To Patient
Insurance Agreement and Consent
As a courtesy to our patients, we assist in filing insurance claims. This allows you to use your orthodontic benefit to lower your portion of the cost of orthodontic treatment, rather than paying the full fee up front and waiting for reimbursement from the insurance company.
Pecularities:

If a peculiarity is unknown to us, or we are given incorrect or incomplete information by you or your insurance company, and it results in an underpayment of estimated benefits, any unpaid amount will become your financial responsibility and applied to your account. We can assist you in an appeal to the insurance company but ultimately the Insurance company will have the final decision.
Initials*
CHANGE IN BENEFITS, ELIGIBILITY OR CARRIER:

Most orthodontic insurance benefits are broken down into multiple payments that are paid over the course of the treatment.
⦁ At any point in treatment, if you change jobs or become ineligible for orthodontic benefits, please notify us immediately and we will average any remaining unpaid benefits into your monthly payments.
⦁ At any point in treatment, if your employer changes insurance carriers, you must notify us immediately. If your new policy has orthodontic benefits, we will file a claim with the new carrier as a courtesy. If this claim is denied, if the estimated remaining benefits are not paid in full, or if the new policy does not have orthodontic benefits, we will average any remaining unpaid benefits
into your monthly payments.
Initials*
INTENTIONAL OR UNINTENTIONAL WITHHOLDING OF BENEFITS:

When benefits are assigned directly to this office, if an insurance company sends you a payment in error, you are responsible for complete reimbursement. If you receive a check from your insurance company, mail or bring it to this office. DO NOT deposit or cash it.
Initials*
Miscellaneous:

⦁ Since payment plans and policies vary between insurance companies, your actual insurance benefit may differ from the amount we have estimated for you. At the conclusion of treatment, ALL UNPAID INSURANCE BALANCES will become your financial responsibility, and we will hold you directly responsible for payment of the entire account before orthodontic appliances are removed.

⦁ Divorced or Separated Parents: if the insurance company issues a payment to the parent who is NOT financially responsible for the account, the parent who is financially responsible (signed contract) for the account will become responsible for complete reimbursement this office.
Initials*
Consent to Assign Benefits for Insurance

I authorize Jeffrey Kwong Orthodontics to file and request assignment of beneftis from my insurance company. I undersand that the estimated insurance is filed and collected on my behalf, however, I am ultimately responsible should the payments not be received.
Initials*
I fully understand the conditions of this insurance agreement, and I agree to abide by the limitations set forth. I also understand that insurance billing is a courtesy to me, and that I am fincially responsible for the full treatment amount, including the estimated insurance benefit. I hereby authorize payment directly to Jeffrey Kwong Orthodontics.
Full Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Child New Patient Information

Patient Information

Responsible Party 1

Responsible Party 2

Other Information

Medical History

New Patient Acknowledgements

Insurance Agreement and Consent