Child Registration Form

Confidential Patient Medical History

First Name* Middle Initial Last Name* Nickname Date*
Address* Apt# Date of Birth*
City* State* Zip* Code Social Security Number
Home Phone* Parent's Work Phone Parent's Cell Phone Sex*
Physician Name Address Physician Phone Employer / college
Pharmacy Name Address Pharmacy Phone Your Email Address*
Name and Address of emergency contact (other than your family home)*
Phone*
How did you hear about us?
Other family members seen here:
Abnormal Bleeding Heart Surgery Seizures
Allergies YN Hemophilia YN Sickle Cell Disease YN
Anemia (Low Iron) YN Hepatitis A or B YN Sinus Problems YN
Arthritis YN High Blood Pressure YN Sleep Apnea (Snoring) YN
Artificial Joints YN HIV or AIDS YN Stroke YN
Artificial Heart Valve YN Hyperactivity YN Thyroid Problems YN
Asthma YN Hyponasal Voice YN Tuberculosis YN
Bed Wetting YN Kidney Problems YN Ulcers YN
Blood Transfusion YN Liver Disease or Hepatitis C YN Upper Airway Infections YN
Cancer / Chemotherapy YN Low Blood Pressure YN Yellow Jaundice YN
Chronic Nose Running YN Mitral Valve Prolapse YN Colitis (Irritable Bowel) YN
Nightmares YN Congenital Heart Defect YN Night Terrors YN
Developmental Delays YN Nocturnal Mouth Breathing YN Diabetes YN
Noisy Breathers YN Earaches YN Pace Maker YN
Epilepsy YN Poor Concentration YN Fainting Spells YN
Psychiatric Problems YN Fever Blisters YN Obesity YN
Headaches YN Restless Sleep YN Heart Attack YN
Rheumatic Fever YN

ALLERGIES

Aspirin YN Codeine YN Dental Anesthetics YN
Erythromycin YN Jewelry YN Latex YN
Metals YN Penicillin YN Tetracycline YN
Other
List any medications including herbals and vitamins:
Signature     Date

Child Dental Questionnaire

For us to get to know the children better and develop a trusting relationship with them, we request that parents remain in the reception area during all visits. Sedation dentistry is available for ages 18 and older. Children would be referred to a special dentist for sedation.

What is your chief dental concern for your child?

When was your child’s last dental exam and cleaning?

Does your child have any toothaches? YN

Is there a bump on the gum? YN

If any, list pain medications given to child.

How often does your child brush?

Do you help them? YN

Is the brush?

Are crooked teeth a concern? YN

For whom? Parentchild

Is your child a big milk drinker? YN

How many cups of juice a day?

How many cups of soda a day?

How many hours of chewing gum a day?

Does your child grind their teeth at night? YN

Is your child a noisy eater? YN

Does your child get frequent sinus or ear infections? YN

Does your child take afternoon naps? YNN/A

Is your child shy around strangers? YN

Does your child have a favorite pet or toy?

Other Comments:

Patient / Guardian Signature Print Patient Name     Date

HIPAA OMNIBUS RULE PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date: [ today's date ]

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Lifetime Dental Care. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please print name of Patient Please sign for Patient / Guardian of Patient
Legal Representative / Guardian Relationship of Legal Representative / Guardian
Your comments regarding Acknowledgements or Consents:

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name OnlyProper SurnameOther

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name Relationship
Name Relationship

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

    It was emergency treatment
    I could not communicate with the patient
    The patient refused to sign
    The patient was unable to sign because
Other (please describe)
   


    Signature of Privacy Officer

PATIENT FINANCIAL POLICY

  1. For those with insurance benefits, we are happy to bill your insurance as a courtesy to you. Please note that your =insurance contract exists solely between you and your insurance carrier. We will file your insurance claim, but we cannot guarantee any benefits. Your insurance plan is a benefit to you to help offset the cost of necessary dental care. Ultimately, you are responsible for the entire cost of your dental treatment. In some cases, if you do have insurance coverage, we may still ask you to pay in full on the date of service. Any questions or comments regarding your benefits should be directed to your insurance carrier. If the balance is not cleared within 60 days, you will be charged a billing fee of $5.00 monthly.
  2. Payment at the time of service is expected, or the estimated portion of the amount that insurance does not cover. Our office accepts the following credit cards: MasterCard, VISA, American Express, Discover and Care Credit. There is a prepay 10% reduction in fees for your next appointment when you make the appointment if paid in full with cash or check at the time of scheduling treatment. Sedation appointments, “Invisalign”, and credit card payments are excluded from the 10% offer. Also excluded are patients with PPO contracts due to the contractual discounts in their policies. (Sedation appointments require pre-payment, Invisalign requires $610.00 non-refundable deposit before sending out case. Some of the Invisalign fee may or may not be reimbursed by your insurance depending upon your policy parameters.)
  3. When the patient’s portion cannot be paid at the time of service and payment arrangements extend beyond 60 days, a billing fee of $5.00 per month will be charged on all outstanding balances regardless of estimated insurance.
  4. A credit qualification will be researched on each new patient before being offered payment arrangements.
  5. A statement for services rendered will be mailed to you every four weeks. Receipt of payment is expected within 21 days of the postmark. The patient’s payment should be mailed with the top portion of the statement to establish the proper crediting of the account.
  6. Your account due is considered delinquent if the requested payment is not received 21 days after billing. If payment is not received, a billing fee of $5.00 per month will be assessed after 60 days, and will appear on the next statement. All fees are subject to change without a new form’s being signed.
  7. A $35.00 charge will be billed to your account for any check returned by the bank for any reason. We will resubmit the check for payment to the bank one time. However, if funds are still insufficient, we will not accept payments by check from you in the future.
  8. There will be no charge for a broken appointment with 24 hours’ notice. This enables us to fill the reserved time slot from our list of patients who are able to come on short notice. Broken appointments with less than 24 hours’ notice will incur a fee of $45.
  9. Before records can be transferred, you must sign a privacy release form and pay the $28.00 x-ray duplicating fee if needed.
  10. Delinquent accounts after 90 days may be sent to a collection agency or small claims court. Any fees incurred for the collection of a debt are the responsibility of the patient or guarantor and will be added to the account.
I have read and understand the financial policy of Dr. Tony Butchert and agree to all the terms described in it.
Patient Signature/Guardian Signature     Date
If signed by Guardian, please print patient’s name above.

Dental Benefits Processing Information

Dental benefit coverage available?

Is there a second dental insurance policy?

The information requested is the minimum required for accurate and efficient billing and processing of your insurance. We will not be able to bill insurance claims without this data.

AUTHORIZATION TO BILL / PROCESS INSURANCE

I hereby authorize my insurance benefits be paid directly to the dentist. I authorize the release of any information required by my insurance company to facilitate the processing of all claims. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy. I understand that I am financially responsible for any balances after 60 (sixty) days whether or not my insurance has settled. Any fees associated with the collection of unpaid balances are the responsibility of the guarantor / subscriber. I certify that I have read or had read to me, if requested, the contents of this form and do realize the risks and limitations of receiving timely insurance reimbursement. I understant that with out the above requested infomation, insurance con not be processed.

Patient Signature/Guardian Signature     Date

 

 

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Free Exam, Cavity Detection & 3-D x-ray*

 

*With Insurance: Cleaning, exam and all x-rays are covered.

*No Insurance: With a paid Cleaning ($88), a complete exam, cavity detection x-rays, and panoramic x-ray are all included.

NEW PATIENT EXCLUSIVE OFFER!

Free Exam, Cavity Detection & 3-D x-ray*

*With Insurance: Cleaning, exam and all x-rays are covered.

*No Insurance: With a paid Cleaning ($88), a complete exam, cavity detection x-rays, and panoramic x-ray are all included.



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Free Exam, Cavity Detection & 3-D x-ray*

*With Insurance: Cleaning, exam and all x-rays are covered.

*No Insurance: With a paid Cleaning ($88), a complete exam, cavity detection x-rays, and panoramic x-ray are all included.





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