New Patient Registration Form

Child’s Name: _____________________________ Soc. Sec. #: ________________________

Sex: Male ___ Female ___ Birth date: __________________________________________

Parents’ Name: ______________________________ Home Phone: _____________________

Address: ____________________________________________________________________ City:_____________________________________________State: _________ Zip: _________

Email Address: ________________________________________________________________

Person Responsible For Payment of Account In Addition To Parents: _____________________

Father Employed By: ___________________________ Phone: __________________________

SSN: _____ ____ ______ Date of Birth: ____________________________________________

Mother Employed By: ____________________________Phone: _________________________

SSN: _____ ____ ______ Date of Birth ____________________________________________

If self-employed, please state business: _____________________________________________________________________________

Who referred you to this practice? _____________________________________________________________________________

Dental Insurance Program: _______________________________________________________

Primary Secondary

Group #: __________________________ Policy Holder: _______________________________

Child attends what school? _______________________________________________________

Medical History

Is child in good general health? Yes / No

Has child had any illnesses recently? Yes / No

Is child taking any medications at this time? Yes / No

Has child ever been hospitalized? Yes / No

Does child have any heart defect or other heart problems? Yes / No

Has child had Rheumatic Fever? Yes / No

Has child ever had a kidney infection? Yes / No

Is child allergic to any medicines? If yes, which ones? Yes / No

______________________________________________________________________________

Does child have any other allergies? If yes, please describe. Yes / No

______________________________________________________________________________

Has child ever had hepatitis? Yes / No

Has child experienced excessive bleeding from a cut or scratch? Yes / No

Please state any other facts about the child’s medical condition that is not described above.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Dental History

Who is your family dentist? _____________________________________________________________________

When was the child’s last dental appointment? _______________________________________________________

When were last x-rays taken? ___________________________________________________________________

How often does the child brush his/her teeth? ________________________________________________________

Are there any other dental concerns? ______________________________________________________________

Is child complaining of any conditions involving the mouth? If so, please describe. ______________________________________________________________________________

Is child taking a fluoride supplement or fluoride vitamin? Yes / No

Has child had topical fluoride treatment? Yes / No

Does child brush teeth with parental supervision? Yes / No

Does child have any harmful oral habits? If so, please describe. Yes / No

______________________________________________________________________________

Has child had a frightening or unpleasant dental experience? If so, please describe. Yes / No

______________________________________________________________________________

What have you told your child about the scheduled dental appointment?____________________

______________________________________________________________________________

Permission for Treatment and Responsibility for Payment

I, being the parent or guardian of the above minor patient, do hereby authorize and request performance of dental services for this patient, and further, the performance of any procedures the judgment of the doctor may deem necessary during the performance of any operation. This includes treatment in the dental office as well as for outpatient care if necessary.

I also authorize the administration of anesthetics or analgesics which may be deemed advisable by the doctor.

Furthermore, I will be responsible for any financial obligations incurred on this child for dental treatment. I understand that payment must be made at the time services are rendered unless other financial arrangements have been made.

I also agree to be responsible for the 15.00 collection fee for any returned checks and reasonable attorney fees if my account becomes delinquent and legal action for its collection is required.

Date: ______________ Signature: _________________________________________________

Witness: ____________________________ Relationship: _____________________________

Signature On File Form

Dental Plan Name: ____________________________________________________________

I hereby accept the foregoing treatment plan and authorize release of any information that is related to this claim. I understand the portion of the Dentist’s charges covered under the dental care plan named above will be paid direct to the dentist. I also understand that I ‘am personally responsible for any portions of those charges that are not covered or paid by the plan.

Employee, Patient or Parent _____________________________________________________

(Signature and Date)

Name of Person Who Referred You Form

WELCOME TO OUR OFFICE! We would like to say “Thank You” to the person who may of

told you about us. If you were referred to our office by another dentist, or a doctor, or a friend, please help us say “thanks” by filling in the following information.

Your Child’s Name: ___________________________________________________________

Name of Person Who Referred You to Us: __________________________________________

If it was a patient, what is their child’s name? _________________________________________

What is their phone number and address? ____________________________________________

____________________________________________________________________________

Acknowledgement of Receipt of Notice of Privacy Practices

* You may refuse to sign this Acknowledgement

I, _____________________________, have received a copy of this office’s Notice of Privacy Practices.

______________________________________________________________________________

Please Print Full Name

______________________________________________________________________________

Signature

_____________________________________

Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

__ Individual refused to sign

__ Communications barriers prohibited obtaining the acknowledgement

__ An emergency situation prevented us from obtaining acknowledgement

__ Other (Please Specify)

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

Consent For Use And Disclosure Of Health Information

Section A: PATIENT GIVING CONSENT

Name: _______________________________________________________

Address: _____________________________________________________

Telephone: ___________________________________________________

Patient #: ____________________ Email: __________________________

Section B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices 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 disclosures we may make of your protected heal information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Officer: C.V. Anderson, D.D.S.

Telephone: 816-353-7200 FAX: 816-353-5162

Address: 4240 Blue Ridge Blvd #800, Kansas City, MO. 64133

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. 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.

Signature

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 health care operations.

Signature: ________________________________ Date: __________________________

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name: _____________________________________________________

Relationship to Patient: ______________________________________________________________

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT

Include completed Consent in the patient’s chart

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my Consent.

Signature: ______________________

Date: ________________________