New Patient Form

My Kids Zone New Patient Form

Patient Information

Phone Type
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Parent / Guardian Information

Parent 1

Marital Status
Relation to Child:
Phone Type:
Phone Type:

Parent 2

Marital Status
Relation to Child::
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Have we treated any other family members?
Has your child had their tonsils or adenoids removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child allergic to any medications?
Is your child currently being treated by a physician?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

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.

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.

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 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.

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Kids Zone

  • Crossroads Location - 8879 Dallas Acworth Hwy., Dallas, GA 30132 Phone: 770-738-KIDS (5437)
  • Woodstock Location - 12926 Highway 92, Woodstock, GA 30188 Phone: 770-738-KIDS (5437)

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