delmarpedo.com - Health History Form

Health History Form
Del Mar Laser Pediatric Dentistry & Orthodontics

12750 Carmel Country Rd. Suite #215
San Diego, CA 92130

(858) 259-1400
1.Tell Us About Your Child
Child’s Name

First NameMiddle NameLast Name
Nickname
MaleFemale
Sibling that we treat
Child's Birthdate

MonthDayYear
Date
Child's Age
Child's Home #
Please enter a valid phone number.
SSN
Child’s Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Mother’s Information
Name
StepmotherGuardian
Employer
Work #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Cellular #
Please enter a valid phone number.
SS #
DL #
3. Father’s Information
Name
StepfatherGuardian
Employer
Work #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Cellular #
Please enter a valid phone number.
SS #
DL #
Marital Status

SingleMarriedSeparatedDivorcedWidowed
4. Who is Accompanying the Child Today
Name
Relationship
Do you have legal custody of the child?

YesNoShared
Is there a child custody order in place that may affect decisions and /or consents for dental treatment?

YesNo
5. Person Responsible for Account
Name
Relationship
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Email
example@example.com
6. Primary Dental Insurance
Insurance Co. Name
Ins. Address
Ins. Phone #
Please enter a valid phone number.
Policy/ID #
Group #
Policy Owner
Policy Owner DOB

MonthDayYear
Date
SSN
Employer
7. Secondary Dental Insurance
Insurance Co. Name
Ins. Address
Ins. Phone #
Please enter a valid phone number.
Policy/ID #
Group #
Policy Owner
Policy Owner DOB

MonthDayYear
Date
SSN
Employer
8. Dental History
Is this your child’s first visit to a dentist?
If not, date of last visit dental visit?

MonthDayYear
Date
Were any X-rays taken at previous dental visits?
Has your child had any dental injuries?

YesNo
If yes, please explain
Why did you bring your child to the dentist today?
Why did you bring your child to the dentist today?

Lip Sucking/BitingClenching/ Grinding teethThumb/Finger SuckingNursing Bottle Habits
Has the child ever had any serious or difficult problem associated with previous dental work?

YesNo
If yes, please explain
Is the child taking fluoride supplements?

YESNO
Is the child’s water fluoridated?

YESNO
Has the child had any pain or tenderness in his/her jaw/ joint (TMJ/TMD)?

YESNO
Does the child brush his/her teeth daily?

YESNO
Floss teeth daily?

YESNO
9. Medical History

Has your child ever had any of the following:

	YES	NO
Heart disease or defects
Autism/ADHD
Hospital Stays
Operations
Heart Murmur
Asthma/Breathing Difficulties
Rheumatic Fever
Anemia or Blood Disorders
Cleft Lip or Palate
Diabetes
Bleeding Difficulties
Mental Retardation
Kidney/ Liver Disease
Hepatitis or HIV/AIDS
Sickle Cell
Convulsions or Seizures
Dizziness or Fainting
Latex Allergies

Please discuss any serious medical conditions the child has had
Please list all medications the child is currently taking:
Please list Drug Allergies:
Child’s Physician:
Phone Number:
Please enter a valid phone number.
Is the child currently under physicians care?

YESNO
Child current health condition

GOODFAIRPOOR
Who may we thank for referring you?

WebsiteFriend Dr.
AUTHORIZATION and RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care to third party payers and / or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. (If payable to the Insured, then payment is due at the time services are rendered) I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services the day they are rendered on my behalf and my dependents.
Signature of Parent or Guardian

Clear

PATIENT CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
1. Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment.
2. Obtaining payment from third party payers (e.g. my insurance company);
3. The day-to-day healthcare operations of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Patient Name:
Relationship to Patient:
Signature:

Clear
Date:

MonthDayYear
Date

Financial Agreement and Authorization for Treatment
We charge a 50% finance fee on all accounts with a balance 60 days or older. Payment is due in full at each appointment. For your convenience we offer the following payment methods, please check the one you prefer……….

CashInsurance Co-payCredit Card [Care Credit/Citi Health
I authorize for my child. I agree to pay all the fees and charges for such treatment.
Signature:

Clear
Date:

MonthDayYear
Date
Financial agreement for dental treatment can be made prior to the commencement of treatment. Dental benefit plans may cover only part of your dental treatment. It is understood that you are responsible for the entire balance of your account. The Contract of dental benefits is between the patient and the insurance company.. You are responsible for all services rendered, regardless if you have dental benefits or not. We bill your insurance company for you as a courtesy. PLEASE REMEMBER THE FINANCIAL OBLIGATION FOR DENTAL TREATMENT IS BETWEEN YOU AND THIS OFFICE AND NOT DEPENDENT UPON INSURANCE.

Authorization and Release

I authorize my dentist to release any information including the diagnosis and records of any treatment or examination rendered to my child during the period of such dental care, third-party payers and/or other heath care practitioners.

I authorize and request my insurance to pay directly to the dentist insurance benefits otherwise payable to Dr. Soudabeh Sharafi.

I authorize and request my dentist to use my signature on file for my signature on all dental insurance forms to expedite computer processing claims.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependents. If any insurance payment has not been received within 60 days the responsible party is billed immediately.

If I do not pay the entire balance within 60 days of the billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed to the bill for services rendered. I realize a failure to keep this account in good standing may result in you being unable to provide additional dental services except for dental emergencies where there will be prepayment. It is your responsibility to ensure your insurance company pays promptly so you can avoid finances charges. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

I agree that I am the responsible party: Because a large percent of the population involves divorces situations it is the policy of this office to collect from the parent who brings the child in for dental services. We can give you a letter as a courtesy so the other parent can reimburse you for his/her percentage, but full payment must be paid at the time of the visit. This is standard for most businesses.

I acknowledge that I have read and agree to the above financial policy.
Signature

Clear
Date

MonthDayYear
Date

Medical History Update Form
Patient’s Name:

First NameLast Name
DOB:

MonthDayYear
Date

	Date	Change in Medical History or Medications	Dentist Signature	Parent or Guardian Signature
1
2
3
4
5
6
7
8
9
10

Should be Empty:

Health History Form

1.Tell Us About Your Child

2. Mother’s Information

3. Father’s Information

4. Who is Accompanying the Child Today

5. Person Responsible for Account

6. Primary Dental Insurance

7. Secondary Dental Insurance

8. Dental History

9. Medical History

PATIENT CONSENT FORM

Financial Agreement and Authorization for Treatment

Medical History Update Form