Forms - Sahouria Pediatric Dentistry & Orthodontics

Child's Information

Child's Full Name *

Nickname

Sex *

Date of birth *

Adoption/Guardianship

Is this the child's first dental visit?

Date of last visit

Purpose of visit

Name of child's pet(s) if any

Child's interests

Name of child's school or preschool

Name of family dentist

Child's previous dentist

What is the reason for this visit?

How did you hear about our office?

First Parent's Information

Parent 1 (full name) *

Date of birth *

Marital Status

Address *

Country

City

State

Zip code

Phone

Cell Phone *

Work Phone

Employer

Employer Phone

Employer Address

Country

City

State

Zip code

SS#

Driver's License #

Email

Second Parent's Information

Parent 2 (full name)

Date of birth

Marital Status

Address

Country

City

State

Zip code

Phone

Cell Phone

Work Phone

Employer

Employer Address

Country

City

State

Zip code

SS#

Driver's License #

Email

Child's Residential Status

Child resides with:

Name of nearest relative not living with you (relationship)

Phone

Address

Country

City

State

Zip code

First Parent's Dental Insurance Information

Name of Insurance Company

Group/Policy No.

Phone

Insurance ID

Address

Apt, suite, etc.

Country

City

State

Zip code

Second Parent's Dental Insurance Information

Name of Insurance Company

Group/Policy No.

Phone

Insurance ID

Address

Apt, suite, etc.

Country

City

State

Zip code

Assignment of Benefits

Instructions

Assignment of Benefits: I hereby authorize payment directly to the above named dentists of the group dental benefits otherwise payable to me but not to exceed the charges shown on the claim. I understand that I am financially responsible for 100% of all charges and any charges not covered by this authorization.

All balances past due 60 days are subject to a finance charge of 1.5% per month (an annual rate of 18%) and/or subject to all legal and collection expenses.

To the above assignment of benefits: *

I agree

Medical Information

Child's Pediatrician *

Phone *

Date of last physical exam *

Is your child under a doctor's care now? *

For what reason?

What medicines or drugs is your child taking? *

Has your child ever been hospitalized? *

When?

Reason?

What medications is your child allergic to? *

Reaction

Please elaborate on the type of allergy.

Does your child have good physical condition? *

Has your child's developmental milestones been attained? *

Are your child's immunizations up to date? *

Dental Information

Was your child bottle fed or breast fed? *

Until what age?

Has your child ever had any injuries to the teeth, mouth or head? *

If yes, please describe

Has your child taken flouride? *

In what form and when? *

Does your child brush regularly? *

Floss regularly? *

Does an adult assist? *

Has either parent or child been treated orthodontically (braces)? *

How would you expect your child to behave in our office? *

Authorize & Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of the treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I further acknowledge the receipt of the Dental Materials Fact Sheet dated October 2001 and HIPPA Privacy Form.

To the above authorization & release. *

I agree

Verification

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