YOUR CHILD'S PERSONAL INFORMATION€¦ · Thank you for selecting our team for your dental care. We...

Date:

Child's Name: MI: Last Name:

Sex: Female Male Birthdate:

Wishes to be called: SSN:

Address:

City: State/Zip:

How did you hear about us?

Name:

Relationship to patient:

Birthdate: SSN:

Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms. If you have any questions or need assistance, please ask us, we are always happy to help in anyway possible!

RESPONSIBLE PARTY (Person responsible for Child's Account)

YOUR CHILD'S PERSONAL INFORMATION

Birthdate: SSN:

Address:

City: State/Zip:

Employer: Occupation:

Employer Address:

City: State/Zip:

Name:

Relationship to patient:

Home Phone: Work Phone: Cell Phone:

Email:

Best way for us to reach you? (please circle) Home Work Cell Email

If by phone, preferred date and time?:

RESPONSIBLE PARTY (Person responsible for Scheduling Appointments)

- New Patient Information (CHILD)

F. R. Dahm D.D.S. P.L.L.C. / 4004 NE 4th Street, Suite 106 / Renton, WA 98056 / Phone: 425.282.6600 / Fax: 425.282.6601 www.freddahmdentistry.com

STEPMOTHER GUARDIAN FATHER

Name Name

Home Phone Cell Phone Home Phone Cell Phone

Work Phone Ext. # Work Phone Ext. #

Email Email

Employer Occupation Employer Occupation

SSN: SSN:

Status: Single Married Divorced Status: Single Married DivorcedWidowed Separated Widowed Separated

Name of Subscriber: Name of Subscriber:

Relationship to Patient: Relationship to Patient:

Subscriber's Birthdate: Subscriber's Birthdate:

Subscriber's Address: Subscriber's Address:

Subscriber's SSN: Subscriber's SSN:

Subscriber's Employer: Subscriber's Employer:

Insurance Co: Insurance Co:

MOTHER STEPFATHER

DENTAL INSURANCE INFORMATION

PRIMARY INSURANCE SECONDARY INSURANCE

GUARDIAN

Insurance Co: Insurance Co:

Group #: Group #:

Insurance Co Phone #: Insurance Co Phone #:

Signature of Parent/Guardian Date

I understand that my dental insurance carrier may pay less than the actual charges for services. I agree to be responsible for payment of allservices rendered on my behalf or my dependents. Furthermore, I authorize the assignment of benefits to be paid directly to F. R. Dahm D.D.S.,P.L.L.C dba Fred Dahm Dentistry.

Thank you for taking the time to complete this form in its entirety. The information you have provided will help us serve your dental healthcareneeds more effectively and efficiently. If you have any questions at anytime, please ask us, we are always happy to help!

AUTHORIZATION AND RELEASE

I authorize the dentist to release all information necessary to secure payment of insurance benefits. I authorize and request my insurancecompany to pay insurance benefits directly to the dentist for all dental services rendered.

- New Patient Information (CHILD)


PATIENT/CHILD NAME: DATE:

Chief Dental Concern for your Child:

Is this your child's first dental visit? Yes No

Previous Dentist's Name:

Date of last visit:

Does your child feel nervous about having dental treatment? Yes No

Has your child ever had a bad dental experience? Yes No

If yes, please explain:

Has your child been seen by an Orthodontist? Yes No

Have there been any injuries to your child's teeth or jaw? Yes No (Falls, Blows, Chips, etc.)

Has your child ever been premedicated for dental work? Yes No

How often does your child brush? Floss?

DENTAL HISTORY (Please answer Yes or No to the following questions)

How often does your child brush? Floss?

Has your child ever been premedicated for dental work? Yes No

Does your child receive fluoride in vitamins, tablets, or water? Yes No

Is your child having any pain or discomfort at this time? Yes No Is your child currently taking any medications? Yes No

If Yes, please list:Has your child been hospitalized during the past 2 years? Yes No

If Yes, please explain:

Has your child been under the care of a medical doctor during the past 2 yrs? Yes No

Physician Name:

Physician's Number:

Has your child taken any medicine/drugs during the past 2 years? Yes No

If yes, please list:

Please list any serious medical condition(s) that your child has or has had:

HEALTH HISTORY (Please answer Yes or No to the following questions)

Page 1 - Patient Health History Form (CHILD)


Y N Y N Y N

AnemiaAngina PectorisAnxiety/DepressionArthritisArtificial Heart ValveArtificial JointsAsthmaBlood DiseaseBlood TransfusionBruise EasilyCancerCongenital Heart DefectCortisone Medicine

Is your child allergic to or reacted adversely to any of the following?

Y N What was the reaction?

Kidney DiseaseLiver Disease

Rheumatic Fever

Allergies

LatexAspirin

Radiation Treatment

Frequent HeadachesGlaucoma

Heart AttackHead Injuries

Heart Murmur

Pain in Jaw Joint

Epilepsy

Mental Disorders

X-ray/Cobalt Treatment

Heart Surgery

Allergy - Hay FeverAllergy - PenicillinAllergy - ErythoAllergy - Sulfa

Heart DiseaseHeart Failure

Other: (please list)

MEDICAL CONDITIONS (Please answer Yes or No to the following conditions)

Fever Blisters/Cold SoresShinglesSickle Cell DiseaseSinus ProblemsStomach ProblemsStrokeThyroid Disease

TuberculosisTumorsUlcersVenereal Disease

Respiratory Problems

High/Low Blood PressureHIV/AidsJaundice

Excessive Bleeding

CoughCosmetic Surgery

Diabetes Nervous Disorders

Emphysema/AsthmaDrug/Alcohol AddictionDizziness

PregnancyPsychiatric Treatment

HemophiliaHepatitis

RheumatismFainting



Any other medications: * If yes, what kind?

Signature of Parent/Guardian Date

Penicillin

TetracyclineErythromycin

Aspirin

AUTHORIZATION OF INFORMATION

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize, Dr. Fred Dahm, and/or dental staff to perform the necessary dental services that I may need.

CodeineSedatives or sleeping pillsDental anesthetic



My signature confirms that I have been informed of my rights to privacy regarding my protected health information, underthe Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will beused to:

ACKNOWLEDGMENT OF PRIVACY PRACTICES

Provide and coordinate my treatment among a number of healthcare providers who may beinvolved in that treatment directly and indirectly.

Obtain payment from third-party payers for my healthcare services.

Conduct normal healthcare operations such as quality assessment and improvement activities.

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the usesand disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices . I understand that my dental provider has the right to change the Notice of Privacy Practices and that Imay contact this office at the address below to obtain a current copy of the Notice of Privacy Practices .

PATIENT NAME:

Signature: Date:

Dependent family members also covered by this Acknowledgement:

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry outtreatment, payment or healthcare operations and I understand that you are not required to agree to my requested restrictions,but if you do agree, than you are bound to abide by such restrictions.


FINANCIAL POLICY

This statement is to inform you of our Financial Policy. We are committed to providing you with the highest quality ofdental care using only the best material and technology available in the market today. We are also committed to providingyou with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health.Our Financial Policy is intended to facilitate excellent service to you while minimizing our administrative cost.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dentalcare provider, our relationship is with you, our patient, not with your insurance company. Our office is not a party to thatcontract. If payment from your insurance company is not received within 60 days from date of service, you will be expectedto 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 payyour benefits directly to our office by signing the authorization on the Assignment of Benefits Agreement at the bottom ofthis form. In order for our office to file your insurance claim, you must bring proof of insurance and notify us of anychanges to your policy at each dental appointment.

Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, Discover andAmerican Express. Outside financing is available through Care Credit upon request and approval.

PATIENT NAME:

Signature of Patient or Parent/Guardian if minor Date

American Express. Outside financing is available through Care Credit upon request and approval.

Returned checks and outstanding balances older than 60 days may be subject to collection fees and finance charges at therate of 1.5% per month (18% annually).

If you have any questions regarding our Financial Policy, please ask. We are committed to providing you with the mostpositive experience in dental care.


PATIENT NAME:

Signature of Patient or Parent/Guardian if minor Date

Our office does require a two (2) business day notice to change or cancel an appointment. In our continued commitment toprovide the highest quality of dental care available to all of our valued patients, a $50.00 dollar fee will be applied if we donot receive the proper two (2) business day notice to reschedule or cancel an appointment.

APPOINTMENT POLICY


YOUR CHILD'S PERSONAL INFORMATION€¦ · Thank you for selecting our team for your dental care. We...

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