1. Tell Us About the Patient - Lone Star Pediatric Dental

Orthodontic Appointment Office Location

Pediatric Dental Appointment

1. Tell Us About the Patient

Name

Last

First

Preferred name

Patient's Birth Date

/

/

MM

DD

YYYY

SS#

Patient's Home Address

MI

Male

Female

City

Patient's Home (

)

School

State

Zip

Siblings that we treat?

Grade

Patient's Age

2. Legal Guardian #1 Information

Name

Last

First

MI

Date of Birth

/

/

Relationship to Patient

MM

DD

YYYY

Employer

Cell # (

)

Home# (

)

Work #(

)

E-mail

SS#

DL#

Appointment reminders via text message? Yes

No

E-mail reminders?

Yes

No

Are you the responsible party?

Yes

No



3. Legal Guardian #2 Information

Name

Last

First

MI

Date of Birth

/

/

Relationship to Patient

MM

DD

YYYY

Employer

Cell # (

)

Home# (

)

Work #(

)

E-mail

SS#

DL#

Appointment reminders via text message? Yes

No

E-mail reminders?

Yes

No

4. Who is accompanying the patient today?

Name

Last

First

MI

Relationship to Patient

Do you have legal custody of this patient? Yes

No

5. How did you first hear about us?

Google Online Reviews Drive by / Walk-in Austin Mom's Blog Post Card/ Mail Other (Please specify)

Facebook Friend / Family Foster Agency Insurance Marketing Event



6. Primary Dental Insurance

Insurance Co. Name Insurance Co. Address

City

Ins. Co. Phone # (

)

ID/Policy #

Policy Owner's Name

Relationship to Patient

SS#

State

Zip

Group #

Last

Date of Birth Policy Owner's Employer

First

/

MM

DD

/

YYYY

7. Secondary Dental Insurance

Insurance Co. Name Insurance Co. Address

City

Ins. Co. Phone # (

)

ID/Policy #

Policy Owner's Name

Relationship to Patient

SS#

State

Zip

Group #

Last

Date of Birth Policy Owner's Employer

First

/

MM

DD

/

YYYY



8. Dental History

Any previous injuries to the teeth, face, or mouth? Yes

No

If yes, please explain:

What is the reason for your visit today?

Please check if the patient has had any of the following problems:

Thumb / Finger Sucking Ice Chewing Tongue Thrust Frequent Snoring Tonsils Removed Bad Breath Tooth Ache Sensitive to Sweets

Nail Biting Lip Sucking / Biting Mouth Breathing Teeth Grinding Adenoids Removed Discolored Teeth Bleeding Gums Sensitive to Hot/Cold

Has the patient ever had pain in the jaw joints(s) (TMJ/TMD)?

Yes No

Has the patient been referred for orthodontics (braces) before?

Yes No

Has the patient ever had orthodontic treatment before?

Yes No

Does the patient have any missing teeth? Does the patient have any pending dental treatment that you know of?

Yes No Yes No

If yes, please explain

Is the patient's water fluoridated?

Yes No



Is the patient taking fluoride supplements? Does the patient brush their teeth daily?

Yes No Yes No

Does the patient floss their teeth daily?

Yes No

Has the patient ever taken biphosphonates, including: (Check all that apply)

Fosamax Boniva Patient's Physician

Didronel Actonel

Aredia Skelid

Zometa

Phone# (

)

Is the patient currently under the care of a physician?

Yes No

Please rate the patient's current physical health

Good Fair Poor



9. Health History

Has the patient ever had any of the following conditions?

Allergies: Seasonal Allergy: Latex Abnormal / Excessive Bleeding Handicaps / Disabilities Heart Disease / Murmur Gastro / Intestinal Issues Frequent Headaches Kidney / Liver Conditions Tuberculosis Pre-Med - Clind Hemophilia / Blood Disorders Any Operations

Allergy: Food

Allergies to any Drug

Allergy: Nickel

ADD / ADHD

Anemia

Asthma

Hearing Impairment

Hepatitis

Autism

Cancer

Rheumatic / Scarlet Fever Diabetes

Epilepsy / Convulsions

HIV+ / AIDS

Respiratory Problems

Nervous Disorder

Birth Defects

Fainting

Pre-Med - Amox

Pre-Med - Other

High / Low Blood Pressure

Any Hospital Stays

Pregnancy (Waiver from Physician required for x-rays)

Please elaborate on anything checked above:

Please list all drugs the patient is currently taking:

Please list all drugs the patient is allergic to:

Date Added

//

OFFICE USE ONLY- DOCTOR INDIVIDUAL SIGNATURE



10. Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and guardians:

Date Added / / May bring to appointments Yes No Date Added / / May bring to appointments Yes No

Date Added / / May bring to appointments Yes No

Date Added / / May bring to appointments Yes No

Cancellations We understand that things come up. Should you have a change in schedule, we kindly ask that you give us 48 hours notice.

Consent for Services As a condition of treatment by this office, payment is due at the time services are rendered for estimated guarantor portion. As a courtesy, Lone Star Pediatric Dental & Braces will help prepare the patient's insurance forms or assist in making collections from the insurance companies and will credit any collections to the patient's account. However, in the event that there is a remaining balance, after insurace has paid, the patient is responsible for the remaining account balance. I understand that treatment plans are honored for a period of three months from the date of the patient examination, provided that there have been no changes in the original diagnosis.

11. I understand that the information that I have given is correct to the best of my knowledge, that

it will be held in the strictest of confidence, and that it is my responsibility to inform Lone Star Pediatric Dental & Braces of any changes to the patient's medical status. If the office accepts my insurance, I am responsible for any co-payments, deductibles or any fees that my insurance does not cover. I consent to Lone Star Pediatric Dental & Braces submitting insurance claims on the behalf of the insurance policy holder, and allowing the provider to accept the assignment of benefits. We reserve the right to charge a $25 NSF fee in the event of any dishonored check for any reason. LSPD&B may enforce that all subsequent payments be paid in cash or certified funds thereafter.

By signing, I agree to the conditions and terms above.

Patient or Legally Authorized Individual Signature

Date: / /

Time:

Print Patient's Full Name:

Witness Signature Date: / /



Time:

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