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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