Form

Please complete the following questions.

To uphold best practices, our office adheres to the guidelines set by the American Dental Board, ensuring that we update our patient files every six months. Please also review our updated cancellation policy.

PATIENT INFORMATION

Last Name

First Name

Middle

DOB

Address

City

Zip Code

Who does the patient live with?

Parent/Guardian's Name

Home Number

Cell/Mobile Number

Which number would you like to have appointments confirmed?

E-mail Address

Does your child play sports?

Does your child have a mouthguard?

PATIENT HISTORY

INDICATE CHANGES TO THE FOLLOWING (PLEASE CHECK ALL THAT APPLY):

If insurance has changed, please provide a copy of the new insurance card

Conditions

Does the patient have any MEDICAL CONDITIONS?

(For example: ADHD, Asthma, Autism, Cerebral Palsy, Diabetes, Epilepsy, Seasonal Allergies, etc.)

If Yes, what conditions?

Does the patient have any HEART conditions?

(For example: Heart Murmur, Congenital Heart Defect, etc.)

If Yes, what conditions?

Allergies

Does the patient have an ALLERGY to LATEX?

Does the patient have any OTHER ALLERGIES?

(For example: Animals, Foods, Medications, Nickel, etc.)

If Yes, what allergies?

Medications

Is the patient currently taking ANY medications/vitamins?

If Yes, what medications/vitamins?

Why is the patient taking this medication?

Dental

Do you (or the patient) have any DENTAL CONCERNS?

If YES, what concerns do you have?

CONSENT FOR TODAY:

X-Rays (if needed)

Fluoride Application

I certify that the information I have given is correct to the best of my knowledge. It will be help in confidence and it is my responsibility to inform this office of changes in the patient's medical status.

I authorize the dental staff to perform all necessary dental treatment the patient may need. I authorize the release of all information necessary to secure benefits otherwise payable to me.

I assign directly Must Love Kids Pediatric Dentistry all insurance payments otherwise payable to me. I understand that I am responsible for the full balance of the account regardless of my dental benefits. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees.

I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the dentist or any member of the staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I affirm that my signatures represents my agreement to all the above mentioned terms.

REFUNDS AND FEES

If your insurance pays more than expected after payments of coinsurance and copayments, we will automatically refund these amounts to the guarantor via a check.
MISSED APPOINTMENTS, LATE CANCELLATIONS, BROKEN APPOINTMENT FEES

Except in emergency situations, you can expect us to be on time for you and we will appreciate the same courtesy. Your appointment time is reserved for you and your child alone, and without notice, in advance, we are generally unable to make use of missed appointment time. Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. Cancellations are requested at least 48 hours prior to the appointment.

A fee of $50 will be applied for appointments that are missed or canceled with less than 48 working hours' notice. If you have two or more missed appointments, we reserve the right to no longer reserve appointments for your family.

Late arrivals- if a patient is late for an appointment, the appointment may need to be rescheduled. This is to ensure that the patients who arrive on time do not wait longer than necessary to see the provider. You may be given the option to wait for another appointment time on the same day if one is available.
If your schedule does not permit you to plan in advance, we might suggest placing you on our list of patients to call on a same day basis.

Parent/Guardian Signature

Date