New Patient Form

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Parent 1

Name:

Social Security Number:

Birth Date:

Drivers License Number:

Address (if different than child):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer Name:

Occupation:

Parent 2

Name:

Social Security Number:

Birth Date:

Driver License Number:

Address (if different than child):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Employer Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder Name:

Relation to Patient:

Policy Holder SSN:

Policy Holder Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder Name:

Relation to Patient:

Policy Holder SSN:

Policy Holder Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

What dental concerns do you have about your child's teeth?

How many times does your child brush his/her teeth per day?

Do you every help your child brush his/her teeth?

Does your child floss every day?

Has your child had any unhappy dental experiences?

Have we treated any other family members? Yes No

Name:

Medical History

Is your child allergic to any medications? Yes No
If yes, please describe allergic reaction.

Does your child have any other allergies (foods, nickel, latex, etc.)?

Is your child currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has puberty and/or menstruation begun? Yes No NA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion? Yes No

If yes, give approximate dates:

Notice of HIPAA and Privacy Policy

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practice before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosure we may make of your protected Health information, and of other important matters about your protected health information. A copy of our HIPAA policy is available upon request. We encourage you to read it carefully and completely before signing this Consent.

Right to Revoke: You have the right to revoke or alter this consent at any time in writing. Please provide revocation notice to KidsZone. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent.

The Following Person May Contact KidsZone Regarding The Above Named Patient

Relationship to Patient

The Following Person May Contact KidsZone Regarding The Above Named Patient

Relationship to Patient

The Following Person May Contact KidsZone Regarding The Above Named Patient

Relationship to Patient

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

Acknowledgement of HIPAA Policy

Appointment Policy

Our office attempts to schedule appointments at your convenience. Your scheduled appointment is reserved specifically for your child. We need ample time to fill an appointment slot for another patient in need of treatment if you are not able to keep your child’s appointment. If you will not be able to keep your child’s appointment, we request 48 hours notice prior to the appointment. If your child’s appointment is cancelled less than 48 hours before the appointment or if you do not come to a scheduled appointment, you will be assessed the no show fee of $50. We will attempt to contact you one week prior and 48 hours prior to your child’s appointment to remind you of the appointment. However, even if you do not receive contact from our office, it is your responsibility to maintain a record of when you have scheduled an appointment for your child.

If you miss two (2) appointments (no show or cancelled with less than 48 hours notice) in a twelve (12) month period, we will require a deposit of $50 before the next appointment can be scheduled. If you miss three (3) appointments (no show or cancelled with less than 48 hours notice) in a twelve (12) month period, we reserve the right to dismiss you from the practice.

I have read and agree to the scheduling information above.

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in the medical status of my child.

I hereby authorize the release of any information pertaining to the medical treatment of my child necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Relationship to Patient:

Date: