For Office Use Only s4

CHART#: ______FOR OFFICE USE ONLY

PATIENT INFORMATION Patient Name: Date: Last First MI Preferred Name Social Security #: Date of Birth: □ Male □ Female Home Phone: Work Phone: Cell Phone:

Email Address: Emergency Contact:

Address: Street City State Zip Code If you have any other children that are patients here, please list name(s): What is the reason for your visit today?

HEALTH INFORMATION Review,initial,date List medications Please check all that apply to your child & add any other condition:

□ ADD □ Down’s Syndrome □ Nervous Disorders □ ADHD □ Epilepsy □ Pregnancy □ AIDS □ Excessive Bleeding □ Radiation Treatments □ Allergies □ Fainting □ Respiratory Problems ______□ Glaucoma □ Rheumatic Fever □ Penicillin Allergy □ Head Injuries □ Rheumatism □ Latex Allergy □ Hearing Impairment □ Seizures □ Codeine Allergy □ Heart Disease □ Stomach Problems □ Arthritis □ Heart Murmur □ Tuberculosis □ Artificial Joint □ Hepatitis □ Tumor(s) □ Asthma □ High Blood Pressure □ Ulcer(s) □ Autism □ Kidney Disease □ Venereal Disease □ Blood Disease □ Liver Disease □ OTHER □ Cancer □ Mental Disorders □ Cerebral Palsy □ Multiple Sclerosis □ Diabetes □ Muscular Dystrophy

Who is your child’s physician?______Phone#:______Is your child currently being treated by a physician? □ Yes □ No If yes, please explain: Does your child have any health problems that need further explanation? □ YES □ NO If yes, please explain: To the best of my knowledge, all of the preceding answers and information provided are true and correct. If my child ever has any change in health, I will inform the doctors at the next appointment. Signature of parent/guardian Date REFERRAL INFORMATION Who referred you to our practice? □ Pediatrician □ Dentist □ Yellow Pages □ Other______Name of person/doctor that referred you:

RESPONSIBLE PARTY INFORMATION

The following is for: □ Mother □ Father □ Other: Relationship______Name: □ Married □ Single □ Other: Social Security #: Date of Birth: Home Phone: Work Phone: Address: Street City State Zip Code Employer Name: Occupation: INSURANCE INFORMATION

The following is for: □ Mother □ Father □ Self □Other: Relationship______Name of Insured: Insured Date of Birth: SS#: Insured Address: Street City State Zip Code Insured Employer Name: Occupation: Insurance Plan Name: Group #:

Insurance Address: Street City State Zip Code Insurance Phone #: Policy ID#:

Please list below anyone other that yourself that might bring your child into the dentist office for treatment. By listing someone else, you are authorizing them to make any decisions regarding treatment and allowing them to access to any confidential information. Name Address Phone#

CONSENT FOR SERVICES As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients that carry dental insurance understand that all dental services furnished are charged directly to the parent/guardian and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patients account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1 ½% per month (18%per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignees, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.

Signature of parent/guardian Date Relationship to patient

Signature of guarantor of payment/ responsible party Date Relationship to patient