Palmdale Children's Dental

Palmdale Children's Dental

Patient Registration form
Child's Name

First NameMiddle NameLast Name
Age
Birth Date

MonthDayYear
Date
Gender
HOME ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
CELLPHONE:

Area CodePhone Number
HOME PHONE:

Area CodePhone Number
MEDICAL ID:
REFERRED BY(SO WE CAN THANKTHEM):
FATHER’S (OR LEGAL GUARDIANS) FULL NAME:

First NameLast Name
SOCIAL SECURITY NUMBER:
DOB

MonthDayYear
Date
DRIVER’S LICENSE NUMBER:
ADDRESS (IF DIFFERENT FROM CHILD’S):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OCCUPATION:
COMPANY NAME:
BUSINESS CONTACT NUMBER
Please enter a valid phone number.
NAME OF DENTAL INSURANCE:
GROUP NUMBER:
MOTHER (OR LEGAL GUARDIANS) FULL NAME:

First NameLast Name
SOCIAL SECURITY NUMBER:
DOB:

MonthDayYear
Date
DRIVER’S LICENSE NUMBER:
ADDRESS (IF DIFFERENT FROM CHILD’S):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OCCUPATION:
COMPANY NAME:
BUSINESS CONTACT NUMBER:
Please enter a valid phone number.
NAME OF DENTAL INSURANCE:
GROUP NUMBER:
HAVE ANY OTHER MEMBERS OF YOUR FAMILY BEEN PATIENT AT THIS PRACTICE?

YesNo
IF YES, WHO?
Medical History
CHILD’S PHYSICIAN NAME:

First NameLast Name
PHYSICIAN’S CONTACT NUMBER
Please enter a valid phone number.
SELECT APPROPRIATE ANSWERS FOR YOUR CHILD

(LEAVE BLANK IF YOU DO NOT UNDERSTAND THE QUESTION)
1. IS THEIR GENERAL HEALTH GOOD?

YesNo
IF NO, EXPLAIN
2. HAS THERE BEEN A CHANGE IN YOUR CHILD'S HEALTH WITHIN THE PAST YEAR?

YesNo
IF YES, EXPLAIN
3. HAS YOUR CHILD GONE TO THE HOSPITAL OR EMERGENCY ROOM FOR A SERIOUS ILLNESS IN THE PAST THREE YEARS?

YesNo
IF YES, EXPLAIN
4. IS YOUR CHILD BEING TREATED BY A PHYSICIAN NOW?

YesNo
IF YES, EXPLAIN
DATE OF LAST MEDICAL EXAM?

MonthDayYear
Date
REASON FOR EXAM:
5. HAS YOUR CHILD HAD PROBLEMS WITH PRIOR DENTAL TREATMENT?

YesNo
IF YES, EXPLAIN
DATE OF LAST EXAM

MonthDayYear
Date
NAME OF LAST DENTIST
6. DOES YOUR CHILD HAD FEARFULLNESS OR ANXIETY ASSOCIATED WITH THE DENTIST?

YesNo
IF YES, EXPLAIN
7. IS YOUR CHILD IN PAIN NOW?

YesNo
IF YES, EXPLAIN
HAS YOUR CHILD EVER HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING?

(PLEASE SELECT YES OR NO FOR EACH)
HEART DISEASE

YesNo
CHEMOTHERAPY

YesNo
FAMILY HISTORY OF HEART DISEASE

YesNo
RADIATION

YesNo
ARTIFICIAL JOINT

YesNo
ARTHRITIS, RHEUMATISM

YesNo
STOMACH PROBLEMS

YesNo
EMPHYSEMA

YesNo
HEART DEFECTS

YesNo
KIDNEY OR BLADDER DISEASE

YesNo
HEART MURMURS

YesNo
STROKE

YesNo
RHEUMATIC FEVER

YesNo
DOWNS SYNDROME

YesNo
SKIN DISEASE

YesNo
AUTISM

YesNo
HIGH BLOOD PRESSURE

YesNo
ADD/ADHD

YesNo
SEIZURES

YesNo
THYROID DISEASE

YesNo
AIDS/HIV

YesNo
ASTHMA

YesNo
SURGERIES

YesNo
HEPATITIS

YesNo
HOSPITALIZATION

YesNo
HERPES

YesNo
DIABETES

YesNo
CANKER OR COLD SORES

YesNo
FAMILY HISTORY OF DIABETES

YesNo
ANEMIA

YesNo
TUMORS OR CANCER

YesNo
LIVER DISEASE

YesNo
EYE DISEASE

YesNo
TRANSPLANTS

YesNo
TUBERCULOSIS

YesNo
IS YOUR CHILD ALLERGIC TO ANY OF THE FOLLOWING?

(CIRLCLE YES OR NO FOR EACH)
ASPRIN

YesNo
LATEX

YesNo
PENICILLIN OR OTHER ANTIBIOTICS

YesNo
LOCAL ANESTHETIC

YesNo
NITROUS OXIDE

YesNo
CODIENE OR OPIODS

YesNo
METAL

YesNo
VALIUM OR SEDATIVES

YesNo
FOOD

YesNo
IS THERE ANYTHING ELSE THE DOCTOR SHOULD KNOW ABOUT YOUR CHILD?
FINANCIAL INFORMATION & OFFICE POLICIES
APPOINTMENT CANCELATIONS REQUIRE 24 HOURS NOTICE.

1. IF YOU MISS TWO OR MORE APPOINTMENTS WITHIN 12 MONTHS WITHOUT GIVING 24 HOURS NOTICE, PATIENT WILL BE DISSMISSED.

2. VERBAL CONFIRMATION IS REQUIRED THE DAY PRIOR TO YOUR APPOINTMENT. WE WILL CALL AND LEAVE A MESSAGE BUT FAILURE TO MAKE CONTACT MAY RESULT IN MOVED OR CANCELLED APPOINTMENTS.

3. IF YOU HAVE A CHANGE IN ADDRESS OR INSURANCE INFORMATION, PLEASE NOTIFY US IMMEDIATELY SO WE MAY UPDATE THE INFORMATION IN YOUR FILE.

4. FULL PAYMENTIS REQUIRED AT THE TIME OF SERVICE UNLESS OTHER ARRANGMENTS ARE AGREED UPON. WE ACCEPT ALL CREDIT CARDS AND CASH PAYMENTS. IF THERE IS DENTAL INSURANCE COVERAGE, THE OFFICE WILL BILL THE INSURANCE. HOWEVER, REMEMBER THE PAYMENT IS STILL YOUR RESPONCIBILITY IN THE EVENT OF DENIALS FROM YOUR INSURANCE.

5. PLEASE READ AND CHECK YOUR MONTHLY STATEMENT CAREFULLY. IF YOU DO NOT RECEIVE YOUR BILLING STATEMENT BY THE 15TH OF THE MONTH, PLEASE CONTACT OUT OFFICE.

6. THERE IS A SERVICE CHARGE OF $25 FOR ANY RETURNED CHECKS

7. THE FOLLOWING POLICY WILL BE STRICTLY ENFORCED. ACCOUNTS NOT PAID WITHIN 60DAYS WILL BE CONSIDERED OVERDUE AND APPROPIATE ACTION WILL BE TAKEN. YOUR ACCOUNT WILL BE SENT TO A PRIVATE COLLECTIONS COMPANY. (UNLESS SPECIFIC ARANGMENTS HAVE BEEN MADE)

I AM AWARE THAT PALMDALE CHILDREN’S DENTAL WILL BE BILLING MY INSURANCE AND RECEIVING PAYMENT
INITIALS
THE GUARDIAN THAT IS PRESENT FOR THE CHILD’S APPOINTMENT IS RESPONSIBLE FOR THE CHILD’S ACCOUNT.
INITIALS
I HAVE READ THE ABOVE AND AGREE TO ABIDE BY THE POLICIES IN THIS OFFICE
PRINT NAME
Signature

Clear
Date

MonthDayYear
Date
PATIENT HIPPA CONSENT FORM
I understand that as a part of my child’s healthcare, this organization originates and maintains health records describing my child’s health history, symptoms, examination, test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment

• A means of communication among the many health professionals that contribute to my care

• A source of information for applying my diagnosis and surgical information to my bill

• A means by which third-party payer can verify that services billed were actually provided

• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
Date

MonthDayYear
Date
Print Patient Name:
Signature

Clear
Relationship to Patient:
Mediation and Dispute Resolution Management
Your care is important to us, and we feel it is vital to your treatment that we communicate openly and honestly.

As such, we request that you: Ask questions and participate in your care, be honest about your history, symptoms, and other important health information, prepare for and keep scheduled visits, and be respectful to our office staff and healthcare providers.

In exchange, we agree that we will: Explain diagnosis, treatment recommendations, and outcomes in an easy-to-understand way, listen to your questions and help you make decisions about your care, keep discussions and records private, and determine when a referral or termination of care is appropriate.

MEDIATION

As a part of our emphasis on open communication, we ask our patients to sign this mediation agreement. While we do not anticipate any issues or concerns during the course of your treatment, if any arise, you (and/or your legal counsel) and your healthcare provider (and/or their legal counsel) agree to meet with a neutral mediator and work toward a solution. Whether or not a solution is found, mediation may postpone but does not remove or block your legal rights. Importantly, you agree that any usage or inference to a "claim" will be understood and read as "potential claim" until the mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. Your signature on this page confirms that should a concern arise in any aspect of the care provided by this office, staff, and affiliated healthcare professionals, you agree to mediate first before pursuing legal action.

EXPERT WITNESSES

Further, if after mediation, you still wish to pursue a court action relating to your care, your signature on this page confirms that you will use, as your expert witness(es) in your legal action, American Board of Medical Specialties board-certified medical witness(es) in the same specialty as Physician. Furthermore, you agree that the physicians who you select will be in good standing and adhere to all of the rules and guidelines of professional conduct of the American Board of Medical Specialties.

As consideration for this agreement, we agree that we will adhere to these same guidelines in selecting our expert witness(es) for any court action relating to your care.

I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.
Patient's or Patient Representative's Signature

Clear
Provider's or Provider Representative's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Palmdale Children's Dental

Medical History

SELECT APPROPRIATE ANSWERS FOR YOUR CHILD

HAS YOUR CHILD EVER HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING?

IS YOUR CHILD ALLERGIC TO ANY OF THE FOLLOWING?

FINANCIAL INFORMATION & OFFICE POLICIES

PATIENT HIPPA CONSENT FORM

Mediation and Dispute Resolution Management