Welcome to OC Kids Dental - Dr. Cima Mazar-Atabaki
-11724-12895400Cima Mazar-Atabaki, DMDBoard Certified Pediatric Dentist24541 Pacific Park Drive Suite 104Aliso Viejo, CA 92656Tel: (949) 362-9860PATIENT INFORMATION Name________________________________________________________________Nickname___________________________________________________________Date of Birth_______________________Age____________Sex_____________Social Security Number____________________________________________Address_____________________________________________________________City_____________________________________State_______Zip_____________Who is accompanying the child today?Name________________________________________________________________RelationBiologicalAdopted/FosterNannyOtherPARENT INFORMATIONParent/Guardians Name___________________________________________Driver’s License #__________________________________________________Address_____________________________________________________________City_________________________________State__________Zip______________Home Phone( )_______________________________________________Cell Phone( )_________________________________________________E-mail______________________________________________________________Work Phone( )________________________________________________DENTAL INSURANCE INFORMATIONPRIMARY COVERAGESECONDARY COVERAGEName of Insured_______________________________________________________ Name of Insured____________________________________________________Date of Birth_________________________SS #_______________________________Date of Birth__________________________SS #__________________________Employer_______________________________________________________________Employer____________________________________________________________Insurance Co___________________________________________________________Insurance Co_________________________________________________________Address__________________________________________________________________Address______________________________________________________________City____________________________________State________Zip_________________City__________________________________State________Zip________________Phone___________________________________________________________________Phone________________________________________________________________Group/Policy #______________________I.D. #____________________________Group/Policy #____________________I.D. #____________________________REFERRAL INFORMATIONPlease share with us how you heard about our office...Sibling(s)_____________________Friend ________________________GoogleWebsiteYelpFacebookPediatrician__________________Dental Office_________________Print Ad___________________Community Event_______________School/Daycare______________Insurance Co_________________Other___________________________________________________________________DENTAL HISTORYWhat is the primary reason for today’s visit?CleaningTrauma/Dental EmergencyConsult for Decay (Cavities)Has your child ever been to the dentist?YesNo (If Yes) Previous Dentist _____________________________________________________Reason for leaving previous dentist________________________________________________________________________________________________________Date of Last Exam_______________________________Date of Last X-ray___________________________________Is your child nervous about previous dental treatment?YesNo (If Yes) Please Describe______________________________________________Does (Did) your child have any of the following Dental Habits (check all the apply) Thumb/Finger SuckingUsed Pacifier (If Yes) up to what age_____________Clench/Grind TeethTMJ/TMD PainSuck/Bite LipsBreast Fed (If Yes) until what age? ____________Speech ProblemsTongue ThrustBite/Chew NailsBottle Fed (If Yes) until what age? ____________Mouth BreatherTongue/Cheek BitingWhat is your child’s Oral Hygiene Routine (check all that apply)Fluoride ToothpasteNon-Fluoridated ToothpasteBrushing by Child___________/dayDental Floss_____________/weekFluoride MouthwashConsume Fluoridated WaterBrushing by Parent_________/dayMEDICAL HISTORYChild’s Physician _______________________________________________Phone ( )____________________Date of Last Visit_________________Address _______________________________________________________________________________________________________________________________________Is your child currently under the care of a physician?YesNo(If Yes) Please explain __________________________________________________Does your child have social/personality/temperament concerns that we should be aware of ? _____________________________________Describe your child’s physical healthGoodFairPoorImmunizations Current?YesNoPlease list all medications and dosages that your child is currently taking______________________________________________________________Anything you would like to discuss with the Doctor in Private? YesNoHas your child been diagnosed and/or treated for any of the following? (check all that apply)Abnormal Bleeding (Hemophilia)Eating DisorderStomach/GI DisordersADD/ADHDEpilepsy/Seizures/ConvulsionsVision ProblemsNO CONDITIONS/HEALTHYAnemia/Blood DisorderHearing ImpairedAllergiesAsthma/Reactive Airway DiseaseHeart Murmur/Heart Defect/Heart SurgeryMedication___________________________________Autism SpectrumImmune Disorder/HIV/AIDSFood__________________________________________Cancer/Tumor/LeukemiaKidney ProblemsLatexSeasonalCongenital Birth DefectsPremature/Low Birth WeightNONEDiabetesSpeech DisorderFinancial Responsibility I assume financial responsibility for all dental treatment and medications provided for my child, and understand that payment is expected on the date services are provided. I request and authorize my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and I therefore am ultimately responsible for payment of services rendered on my behalf or my dependents.Signature DateAuthorization and ReleaseTo the best of my knowledge the information I have given on this form is correct, and I understand that providing and 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 medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or exam rendered to my child during the period of such dental care to third party payers and/or their health practitioners.I have received a copy of this office’s Notice of Privacy Practices. I consent to their use and disclosure of my children(s) Protected Health Information to carry out treatment, payment activities and health care operations.Signature DateAppointment PolicyWe greatly appreciate your efforts in honoring scheduled appointments and wish to provide all of our patients with the highest quality dental care in the most reasonable time possible. Please notify us 24 hours prior to your scheduled appointment if you will be unable to make it. If a patient fails or cancels two (2) scheduled appointments without 24 hours advanced notice, we will institute a broken appointment fee of $55. The fee must be settled prior to scheduling any future appointments. Initial:_____________________ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND DENTAL MATERIALS FACT SHEET ________________________________________________________________________________________________________________________ Signature DateDentist SignatureDateOC KIDS DENTALA Pediatric Dental PracticeCima Mazar-Atabaki D.M.D., M.S.24541 Pacific Park Drive Suite 104 / Aliso Viejo, CA / 92656 / Phone: (949) 362-9860 / ................
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