Apply Step 1 of 5 20% Tell us about your child:Name(Required) First Middle Last NicknameAge(Required)Date of Birth(Required)Address(Required) Street Address State / Province / Region ZIP / Postal Code Cell Phone(Required)Emergency contact not living with you Medical History:Childs physicianDate of Last Physical ExamPhysician AddressPrimary Physicians #Is your child allergic to Latex?(Required)YES/NO?Please Check, if your child has been treated for any the following:(Required) ADD/ADHD Anemia Asthma Attacks/Seizures Autism/Aspersers Cancer/tumors Birth defects Diabetes Recurring headaches Pregnancy Liver disease/GI Kidney disease Heart disease Rheumatic fever Hepatitis (Type) Lip Palate/Cleft Cerebral Palsy Physical Delays Mental Delay Bleeding/blood transfusion HIV Blow in the heart Other Problems None Please explain any items verified above:Has your child had any health problems?(Required)YES / NO If “yes” explainAny problems at birth?(Required)YES / NO If “yes” explainIs your child allergic to anything?(Required)YES / NO If “yes” explainHas your child been hospitalized?(Required)YES / NO If “yes” explainIs your child taking any medications?(Required)Does your child have any of the following habits?(Required) Sucking lip Sucking tongue or finger Grinding teeth Pacifier None You could describe your child as(Required) Shy Scared Apprehensive/Nervous Sociable None Has your child had any unfavorable reactions from any dental office?(Required)If “yes” explainHow did you hear about our office?AdvertisementInternetPhone bookCurrent patient Parent/Guardian Information:Mother - Stepmother - Grandmother - Guardian - OtherName First Last Date of BirthAddress Street Address City State / Province / Region ZIP / Postal Code Home Number(Required)Cell Phone(Required)OccupationWork PhoneEmail Is It OK to Contact You by Email?Yes / No? Father - Step Father -Grandfather – Guardian - OtherName First Last Date MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home NumberCell PhoneOccupationWork PhoneEmail Is It OK to Contact You by Email?Yes / No? THE PARENT AUTHORIZATION, LIABILITY AND AGREEMENT PERMISSION FOR DENTAL EXAMINATION AND/OR TREATMENT OF UNDERAGE CHILDI am the parent or guardian of... (Please list all the children that have an appointment):(Required)Enter Name: and Date of Birth:... Who is a minor child and I authorized and consented for this minor to any x-ray, examination, anesthetic, sedative, or dental treatment surrendered under general, direct, or indirect supervision of Dr. Rick and her associates, staff members, or agents, such as he/she may deem necessary. This authorization shall remain in effect until the authorization is cancelled and sent in the form of a letter by me.I authorize the following people to bring my child to Healthy Smiles PA for treatment:(Required)Enter Name: , Date of Birth , Patient Relationship:◊ FINANCIAL LIABILITY ◊ Assume financial responsibility for all dental treatments and medications provided to my child and understand that payment is expected for services from the date provided. I hereby authorize the dentist to release all the information necessary to ensure payment for the treatment. I authorize the use of this signature in all my insurance presentations and authorize direct payment to Healthy Smiles for the dental benefits I'm sure to pay. I understand that my dental insurance company may pay less than the actual utility bill and therefore Am ultimately responsible for paying for the services they have done to my child ◊ STATEMENT OF PRINCIPLES ◊ In order to serve our patients better, we have instituted a declaration of cancellation. If you cannot attend the appointment, please contact us 24 hours in advance to cancel or move the appointment. Failure to keep the appointment causes an inconvenience for employees of the office as well as other patients who may have the opportunity to keep the appointment time. In addition, being late for an appointment causes all subsequent ones to fall behind schedule. It is for that reason and to respect our patients, that your appointment will be "Lost" if you are ten or more minutes late. The family will be dismissed the second time this occurs. (if you have two children who have an appointment and lose it, it equals two missed appointments.) Your time is valuable, and we do everything we can to respect it. We only ask that the same courtesy be paid to us and other patients and get to your appointment on time. ◊ RECOGNITION ◊ I read, understand, and agree to comply with all the above statements. And I affirm that the information I have given in this formulation is correct, and I understand that giving incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's health status, change of safety, or contact information. Finally, all the authorizations you have given will in effect be that I cancel the authorization in a written form. HEALTHY SMILES RULES At Healthy Smiles, our goal is to help our patients maintain optimal oral health and achieve the best possible dental treatment and for this reason: I. We are not allowing parents in OP; Patients will go in by themselves. If patient gets nervous or scared, we will call parent back with patient immediately. _____ (initials) II. If other children are brought along and they are over 5 years old, they will be required to wait in waiting room. ______ (initials) III. If more than one of your children have appointments, we will try to get them back at the same time in separate rooms but at times due to how busy we get we might not be able to do this and unfortunately, we cannot permit your other children to come back to the same room due to limited space. _____ (initials) IV. Please avoid bringing other people/children to appointments ______ (initials) V. Phone usage including phone calls and video recordings prohibited in our operatories, ALWAYS. ______ (initials) VI. After 2 missed appointments (no shows) we will no longer schedule future appointments for your child, and all future appt will be cancelled _____ (initials) VII. If cavities are diagnosed on this appointment and Doctor can do treatment in office (without nitrous or sedation being needed) it WILL NOT be done on the same day.(unless there is a cancelation same day ) It will need to be scheduled for another day which will more than likely be ONE YEAR out due to our high volume of patients. ______ (initials) Please do not hesitate to let us know of any questions or concerns you may have. Thank you!Enter Your Name(Required) First Last Enter Initials(Required)For example, if your name is Ian Magley, enter your initials as IM.Signature(Required)Date(Required)
