Single Patient Form

Dentistry for Children and Young Adults
Name
First Last
DOB
MM slash DD slash YYYY
Male / Female
Location
Mother/ Guardian
Name
Status
Home Address
Street Address Address Line 2 City State ZIP Code
Res#
Bus#
Cell Phone #
Email
Social Security #
Employed by
Present Position
Father/ Guardian
Name
Status
Home Address
Street Address Address Line 2 City State ZIP Code
Res#
Bus#
Cell Phone #
Email
Social Security #
Employed by
Present Position
Purpose of child's visit:
Sibling's Name & Age:
Referred by
Someone, other then than a parent, to notify in case of an emergency

(Name and Phone #)
Primary Dental Insurance Coverage:
Employee Name
First Last
Employer Name
First Last
Name of Insurance Co.
Telephone
Policy #
Social Security #
Group #
Signature

If there is a secondary insurance policy please inform us.

Release:

I authorize the dentists to perform diagnostic procedures and treatment as may be necessary for proper dental care.

I authorize release of any information concerning my child's health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

I authorize release of information concerning my child's health care, advice and treatment to other healthcare provider.

I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me.

I understand that my dental care insurance carrier or payer of my child's dental benefits may pay less than the actual bill for services. I also understand that I am financially responsible for payments, in full of all accounts by signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid in whole or in part, by my dental care payer. Should the account be referred to an attorney for collection, the undersigned shall pay all reasonable attorneys' and collections fees.

I certify that I have read, understand, and have responded truthfully to the above questions I will not hold Dr.Garrastazu or any member of his staff responsible for any errors or omissions I may have made in the completion of this form.
Parent Guardian Signature
Print Name
Dental History
1: Is this your child's first time visiting the dentist? (If yes, skip to #7)
- Yes
- No
2: Were any X-rays taken on your child's previous visit?
- Yes
- No
3: Have any cavities been noted in the past ?
- Yes
- No
4: Have any teeth (baby or permanent) been removed by extraction?
- Yes
- No
5: Have your child ever had occlusal sealants?
- Yes
- No
6: Has your child had any problems with dental treatment in the past?
- Yes
- No
7: Have there been any injuries to the teeth, such as fall, chips, ect.?
- Yes
- No
8: Has your child ever received a local anesthetic?
- Yes
- No
9: Is there a history of missing or extra teeth in the family?
- Yes
- No
10: How does your child receive fluoride?
- fluoride water
- fluoride rinse/ gel or toothpaste
11: When does your child brush his/her teeth?
- Upon wake up
- After eating and food
- After Meals
- At bedtime
12: Does your child think there is anything wrong with his/her teeth ?
- Yes
- No
Medical History
Name of your child's physician and phone#
1: Is your child receiving medication?
- Yes
- No
2: If yes please list them
3: Is your child allergic to penicillin, antibiotics, or other drugs?
- Yes
- No
4: If yes please list them
5: Is your child allergic or sensitive to any metals?
- Yes
- No
6:Enter in metals
7: Is your child allergic or sensitive to latex?
- Yes
- No
8: Does your child have any allergies?
- Yes
- No
9:If yes please list them
10: Has your child ever had surgery?
- Yes
- No
11:If yes please list them
12: Does your child experience severe or prolonged bleeding?
- Yes
- No
Has your child had a history of:
- diabetes
- heart problems
- asthma
- cancer
- kidney infection
- rheumatic fever
- epilepsy
- cerebral palsy
- hearing loss
- congenital birth defects
- mental retardation
- down's syndrome
- ADHD
- autism
- infections
- speech impediments
- strong gag reflex
- fainting
- seizures
- dizziness
- behavioral/learning disabilities
- eyesight problems
Does your child have a health problem not listed?
Parent/Guardian Signature:
Name
Dentist's Signature
Name
Date
MM slash DD slash YYYY
Patient consent form

CHARGES FOR SERVICES RENDERED All charges for office services are due at the time of my visit to THE LITTLE TOOTH DOCTOR (the ‘Practice’). If an insurance claim is filed by the Practice, I request that payment of all benefits be made on my behalf to the Practice.

FINANCIAL RESPONSIBILITY I understand that I am financially responsible for all charges for dental services rendered on my child’s behalf, including those not paid or reimbursed by my insurance company. I am aware of the fact that my insurance carrier may deny payment for services rendered. If payment is denied, I agree to be personally liable and fully responsible for payment due.

SHARING/DISCLOSING HEALTH INFORMATION I authorize the practice to share, disclose or otherwise release dental information about my child to my insurance company or any authorized entity involved in his/her oral healthcare in accordance with the provisions of HIPAA (i.e., related to treatment, payment or oral healthcare operations). I further authorize the practice to gain access to healthcare records with information relevant to my child’s treatment form any and all other healthcare providers, including but not limited to hospitals, laboratories, physicians, and others.

TREATMENT I further authorize and consent to the Practice’s dentist, their assistants, and other Practice professional staff providing outpatient dental treatment, supplies, services, equipment and other items related to my child’s oral healthcare as determined to be necessary in their professional judgment. I will always be informed of the nature and purpose of the treatment, and potential common side effects thereof, as well as alternative treatment modalities, the approximate estimated duration of my child’s oral healthcare, and that I am able to withdraw my consent for treatment either orally or in writing whether prior to or during the anticipated treatment period.

EMERGENCY In the event that a life-threatening emergency occurs while my child is in attendance at the Practice – in which emergency medical care or treatment is required – I hereby authorize the Practice and its related providers to arrange for the care and treatment necessary to address my child’s emergency medical condition. I further authorize the treating facility or medical personnel to provide emergency medical care and treatment and I agree to be responsible for all medical and related costs associated with such emergency and follow-up medical treatment

CANCELLATION I agree that I will provide at least twenty-Four (24) hours’ notice to be Practice when cancelling an appointment and understand that failure to provide such notice may result in a cancellation fee.
Parent / Guardian Name
Name
Parent Guardian Signature
Date
MM slash DD slash YYYY
Important Notice

Insurance is a contract between the patient and their insurance company. It is the responsibility of the patient’s parents, guardian, or patient age eighteen or older, to know how their insurance works and to inform us of any changes in their insurance coverage. Our office personnel will assist you in filing your insurance claim in order to maximize your benefits. If for any reason your insurance company does not pay within forty-five days for services rendered, the balance is due and payable in full by the responsible party.

We will always make every effort to assist you in recovering benefits form your insurance company but payment to the doctor for services rendered is ultimately the responsibility of the patient’s parent, guardian, or patient eighteen or older.
PARENT OR LEGAL GUARDIAN:
Signature Print
Date
MM slash DD slash YYYY
PATIENT IF AGE 18 OR OLDER
Signature Print
Date
MM slash DD slash YYYY

Signature

Dental History

Medical History

Patient consent form

Important Notice