New Patient Form New Patient Form Step 1 of 4 - Background Information 25% Child's Name*NicknameSex*MFBirth Date* Date Format: MM slash DD slash YYYY Age*Reason for this visit?*Is this your child's first dental visit?*YesNoDate of last visit Date Format: MM slash DD slash YYYY Previous DentistYour child's attitude toward previous dental care?Have we seen other children in your family?*YesNoNamesHow did you hear about our office? Medical InformationPediatrician Name*Address*Phone*Is your child taking any medication?*YesNoWhat kind?ReasonHas your child ever been hospitalized?*YesNoWhen?Reason Has your child had a history or difficulty with any of the following:Allergies*YesNoAsthma/Breathing Problems*YesNoArthritis*YesNoAutism*YesNoAnemia/Bleeding*YesNoBones*YesNoCancer/Tumors*YesNoCerebral Palsy*YesNoCleft Lip/Palate*YesNoDevelopmental*YesNoDiabetes*YesNoEyes, Ears, Nose, Throat*YesNoHearing*YesNoHeart*YesNoKidney*YesNoHepatitis*YesNoImmune Deficiency*YesNoLiver*YesNoGeneral Anesthesia/Surgery*YesNoSeizures/Epilepsy/Convulsions*YesNoStomach/Intestinal*YesNoSyndromes*YesNoOtherIf you answered yes to any above, please give details here.Does your child have any emotional or school problems?*Allergies to medications* Dental InformationWas your child bottle fed?YesNoUntil what age?Was your child breast fed?YesNoUntil what age?Does your child have any mouth habits, such as:Finger/thumb suckingYesNoPacifierYesNoOtherHas your child ever had any injuries to their teeth, mouth or head?*YesNoWhen?DetailsHow would you expect your child to behave in our office?Describe your child:* Outgoing Shy Stubborn Anxious Frightened Age Appropriate How may we help to make this visit a positive experience for your child?Add ChildAdd ChildRemove Child Additional ChildChild’s Name*NicknameSex*MFBirth Date* Date Format: MM slash DD slash YYYY Age*Reason for this visit?*Is this your child’s first dental visit?*YesNoPrevious DentistDate of last visit Date Format: MM slash DD slash YYYY Your child’s attitude toward previous dental care? Medical InformationPediatrician Name*Address*Phone*Is your child taking any medication?*YesNoWhat kind?ReasonHas your child ever been hospitalized?*YesNoWhen?Reason Has your child had a history or difficulty with any of the following:Allergies*YesNoAsthma/Breathing Problems*YesNoArthritis*YesNoAutism*YesNoAnemia/Bleeding*YesNoBones*YesNoCancer/Tumors*YesNoCerebral Palsy*YesNoCleft Lip/Palate*YesNoDevelopmental*YesNoDiabetes*YesNoEyes, Ears, Nose, Throat*YesNoHearing*YesNoHeart*YesNoKidney*YesNoHepatitis*YesNoImmune Deficiency*YesNoLiver*YesNoGeneral Anesthesia/Surgery*YesNoSeizures/Epilepsy/Convulsions*YesNoStomach/Intestinal*YesNoSyndromes*YesNoOtherIf you answered yes to any above, please give details here.Does your child have any emotional or school problems?*Allergies to Medications or Food* Dental InformationWas your child bottle fed?YesNoUntil what age?Was your child breast fed?YesNoUntil what age?Does your child have any mouth habits, such as:finger/thumb sucking?YesNopacifier?YesNoOtherHas your child ever had any injuries to their teeth, mouth or head?*YesNoWhen?DetailsHow would you expect your child to behave in our office?Describe your child* Outgoing Shy Stubborn Anxious Frightened Age Appropriate How may we help to make this visit a positive experience for your child?Add ChildRemove Child PARENT 1First Name*Last Name*Middle InitialAddress*City, State, Zip*Home PhoneCell Phone*Work PhoneEmail* Occupation PARENT 2First NameLast NameMiddle InitialAddress (if different from above)City, State, ZipHome PhoneCell PhoneWork PhoneEmail OccupationElite Pediatric Dentistry may leave protected Health Information (including patient's name, diagnosis, and date of service) on the following* Home Phone Work Phone Cell Phone Email FINANCIAL POLICY and AUTHORIZATION In my absence, I hereby give authorization for the person(s) listed below to bring my child(ren) to Elite Pediatric Dentistry and to consent for any and all recommended dental/medical services.Authorized Person 1NameRelationship to child(ren)Contact NumberAuthorized Person 2NameRelationship to child(ren)Contact NumberAuthorized Person 3NameRelationship to child(ren)Contact Number Your child’s estimated share of cost is due and payable on the day the treatment is performed, unless prior approved financial arrangements have been made. Understand that dental insurance may cover only part of your child’s dental treatment, based on your specific dental benefit plan. We will do our best to provide you with an estimate based on your plan. Please understand that the contract for dental insurance is between you and your insurance company. Any disputes of coverage need to be handled through the insurance company directly by you. By signing, I accept as my personal responsibility all charges to my child’s account regardless to any insurance coverage. To avoid missed appointment charges we request that cancellations are made 48 hours prior to the appointment. In doing so this appointment may then be made available to another family. A charge of $50.00 will automatically be placed for two consecutive broken appointments. A broken appointment is considered a "no show" or cancelling an appointment the same day. I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to determine appropriate and healthful dental treatment. If there is any change in my child's medical status I will inform the dentist. I authorize the dental insurance company provided to this office, to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.SIGNATURE*RELATIONSHIP TO CHILD*DATE* Date Format: MM slash DD slash YYYY
