New Patient Child Registration Form Full St. Charles, IL

Patient Information

Name of Minor/Child (required)

Date

Gender
MF

Birth Date: (required)

Age:

Family Status

Social Security #:

Hobbies:

Referred By:

Phone Home:

Parent/Guardian Name:

Cell:

Preferred Confirmation Method:Home PhoneWork PhoneCell PhoneE-MailText Msg

Address:

E-mail Address:

Emergency Contact Information:

Relationship:

Phone:

Health Information

X Artificial Heart Valves X Artificial Joints X AIDS/HIV X Asthma X Cancer X Diabetes X Diet Controlled Diabetes X Insulin Dependant Diabetes X Anemia X Epilepsy/Seizures

X Mononucleosis X Fainting/Dizziness X Convulsions X Cardiac Stent X Heart Problems X Heart Murmur X Bladder Problems X Hepatitis X Cerebral Palsy X Measles X Tuberculosis X Mumps X Sinus Problems X Blood Disease X Drug/Alcohol Abuse X Hearing Problems X Kidney Disease

X Liver Disease X Thyroid Problems X Psychiatric care X Stroke X Ulcers

AllergiesX Amoxicillin Allergy X Aspirin Allergy X Codeine Allergy X Dental Anesthetics X Latex Allergy X Penicillin Allergy X Tetracycline Allergy X Sulfa Drug Allergy X Other Drug Allergies

Minor/Child's Physician

Phone:

Date of Last Physical Exam

Results:

Is Minor/Child under care of physician now?YesNo

If so for what condition(s)

Receiving any medication or drug(s)?YesNo

Ever been hospitalized?YesNo

Ever had surgery?YesNo

Medications:

Dental History

Date of last visit to dentist:

For What Service:

Has your child complained about dental problems?

YesNo

What water do you drink?

Well WaterCity WaterBottled Water

Does your child brush teeth daily?

YesNo

Have you ever had your water tested for fluoride?

YesNo

Does your child floss every day?

YesNo

Is fluoride taken in any form?

YesNo

Any injuries to the mouth, teeth, head?

YesNo

Any unhappy dental experiences?

YesNo

Any mouth habits-thumbsucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?

YesNo

The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services for my minor/child that may be needed during diagnosis and/or treatment.

Please sign with mouse or finger:

Date:

Person Responsible For Payment

Name:

MaleFemale

MarriedSingleOther

Social Security #:

Birth Date:

Phone (Home):

(Work):

Ext:

Cell:

Address:

City:

State:

Zip Code:

Credit Card Authorization (optional)

Credit Card Number:

Circle One:MCVisaDiscoverAmEx

Expiration Date:

3 digit security code:

Name On Card

Signature(to be signed at the office)

_________________________________

Insurance Information

Primary

Name of Insured:

Is Insured a patient?YesNo

Insured's Birth Date:

ID #:

Group #:

Insured's Address:

Insured's Employer Name/Phone:

Address:

Patient's relationship to insured:SelfSpouseChildOther

Insurance Plan Name and Address:

Secondary

Name of Insured:

Is Insured a patient?YesNo

Insured's Birth Date:

ID #:

Group #:

Insured's Address:

Insured's Employer Name/Phone:

Address:

Patient's relationship to insured:SelfSpouseChildOther

Insurance Plan Name and Address:

Consent for Services

I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions whether manual or electronic.

I authorize the dentist to release all information necessary to secure payment of benefits.

A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

It is my responsibility to inform this office of any changes the medical status of my minor/child. I authorize the dental staff to perform any necessary dental services that my minor/child may need during diagnosis and/or treatment.

I have received a copy of the Notice of Privacy Practices of Michele S. Horton, D.D.S.,FAGD , PC and have been given an option to opt out.

I have read the above conditions of treatment and payment and agree to their content.

Please sign with mouse or finger:

Patient, Parent, Guardian:

Date:

Relationship to Patient:

Guarantor of Payment/Responsible Party:

Date:

Relationship to Patient:

Drs Horton & Vranas, INFORMATION RELEASE AND AUTHORIZATION FORM

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient

Date of birth:

I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.

This information may be released to:

Spouse

Child(ren)

Other

Information is not to be released to anyone

I understand that I have the right to revoke this Authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by this rule. I understand that my dental provider cannot condition treatment on whether I sign this Authorization.

This Authorization will remain in effect until terminated by me in writing or until the following date:

MESSAGES

Please call:

my homemy workmy cell

If unable to reach me:

You may leave a detailed message

please leave a message asking me to return call

Other

X I agree to two way text messaging with Horton & Vranas DDS until I inform them to STOP.

It is my responsibility to notify Drs Horton & Vranas of changes and to complete a new form.

Date

Patient/Authorized Person (Please Print)

Relationship to Patient

AUTHORIZATION FOR TREATMENT OF A MINOR BY DELEGATED PERSONS

I hereby authorize that the following persons have my permission to seek and authorize dental treatment of the above named minor child in my absence and that his/her protected dental information may be shared.

Name:

Relationship to Patient

Phone Number:

Name:

Relationship to Patient

Phone Number:

It is my responsibility to notify Drs. Horton & Vranas of changes and to complete a new form.

Date

Patient/Authorized Person (Please Print)

Relationship to Patient