Step 6 of 7
Has the patient ever had any of the following? Please select yes/no for each.
Any other health problems that need clarification?
Has the patient ever been hospitalized, had a serious injury or illness or had surgery? If yes, please describe:
Is the patient current with all immunizations?
Please list all medications the patient is currently taking:
Please list any allergies (and reaction) to medication:
Supplemental Questions for Ages 12+ (for diagnosing/prescribing purposes)
Is the patient pregnant or nursing?
Is the patient on birth control?
Is the patient using recreational drugs, tobacco or drink alchol?
Dental Health Information
Step 7 of 7
Is this your child's first dental visit? If not, how long since last visit?
Were x-rays taken at the previous dentist?
Have there been any injuries to the teeth, face or mouth? If yes, please explain:
Has your child ever had any pain or tenderness in his/her jaw join (TMJ/TMD)?
Does your child brush his/her teeth daily?
Does the patient brush with fluoridated toothpaste?
Does your child floss his/her teeth daily?
Is your child taking a fluoride vitamin supplement or drinking fluoridated water?
Does your child need or has it ever been recommended or required that your child take an antibiotic pre-medication prior to dental treatment?
Has the patient ever experienced any of the following? Please check all that apply:
Yes, I understand that the information I have given is true to the best of my knowledge and that it is my responsibility to inform this office of any changes in medical history.
HIPAA Notice Of Privacy Practices
At Kids Care Dental & Orthodontics, our mission is to deliver an awesome dental visit to every person, every time. We want to deliver high quality care in an environment that provides personalized attention for each guest. That’s why our office policies are designed with the patient in mind. Please read through our policies carefully.
Please initial each box below:
Financial Policy – It is our policy to receive the patient’s portion of payment in full at the time of service.
Our office works with most insurance companies and we will bill them as a courtesy to you. For your convenience, we accept cash, personal checks, money orders, and credit card payments at the time of service. The practice also has special arrangements with a few financial institutions (CareCredit and DentalBanc) that may also fit your needs.
Insurance and Authorization – We would be happy to file a dental claim with your insurer on your behalf, but you are ultimately responsible for all charges.
We do ask that you read your policy thoroughly so that you are fully aware of the benefits provided and the limitations imposed. You should be aware that different insurance companies vary greatly in the types of coverage available and that some companies take care of claims promptly and others delay payment for many months. We will do everything possible to see that you receive the full benefits of your policy; however we cannot guarantee any estimated coverage. By signing this document, you agree that you are ultimately responsible for payment of services rendered and responsible for paying any co-payment and deductible that your insurance does not cover. You also authorize Kids Care Dental & Orthodontics to release all information necessary to secure the payment of benefits and assign directly to Kids Care Dental & Orthodontics all insurance benefits otherwise payable to you.
Estimates – We will give you an ESTIMATE for your portion based on the information given to us by your insurance carrier.
Please remember that this is ONLY an estimate. We will provide you with written treatment plans at your new patient exam and all recall (six month checkup) appointments. A treatment plan estimate includes our fee, what insurance is ESTIMATED to cover and what your out of pocket expenses will be. If you have insurance, you must remember that these are only estimates based on the information provided. Treatment plans may change depending on the needs of your child. We will always do our best to keep you informed of any changes.
Broken Appointments – We ask that you give us at least 24 hours’ notice before cancelling an appointment.
Because of the personalized care that Kids Care Dental & Orthodontics provides, the patient’s appointment time is reserved just for them. While we understand that emergencies sometimes arise, in order to be respectful of the needs of all patients we ask that if the patient is unable to attend their next appointment, please call our office at least 24 hours in advance. No show appointments and appointments cancelled with less than 24 hours’ notice may be subject to a $50.00 cancellation fee.
Release of Liability and Assumption of Risk – I acknowledge that enjoyment of various play activities at Kids Care Dental & Orthodontics (including the carousel and playground) is based upon my, as the parent or guardian of minor, executing this Release of Liability and Assumption of Risk.
I further acknowledge that my child or minor ward is voluntarily participating in these activities. I understand there are numerous risks and dangers involved in these activities including but not limited to: falling off of the equipment or otherwise injuring oneself on or near the equipment; experiencing electric shock; or the negligence (but not willful or fraudulent conduct) of Kids Care Dental & Orthodontics, and all of their employees, all of which may lead to injury or death. I hereby agree to assume all risks and dangers to my child or minor ward, whether or not listed herein. Additionally, I hereby release and waive on behalf of my child and, if applicable, my minor ward, to the extent permitted by law, all claims or causes of action against Kids Care Dental & Orthodontics and all of their affiliates, officers, directors, shareholders, employees, contractors, agents, heirs, and assigns. By initialing this Release of Liability and Assumption of Risk, I acknowledge that I have read and understand the provisions contained herein.
I have reviewed the office policies and have been given the opportunity to ask questions to clarify any policy I did not understand.