New Patient Child Registration

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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

Artificial Heart ValvesArtificial JointsAIDS/HIVAsthmaCancerDiabetesDiet Controlled DiabetesInsulin Dependant DiabetesAnemiaEpilepsy/Seizures

MononucleosisFainting/DizzinessConvulsionsCardiac StentHeart ProblemsHeart MurmurBladder ProblemsHepatitisCerebral PalsyMeaslesTuberculosisMumpsSinus ProblemsBlood DiseaseDrug/Alcohol AbuseHearing ProblemsKidney Disease

Liver DiseaseThyroid ProblemsPsychiatric careStrokeUlcers

AllergiesAmoxicillin AllergyAspirin AllergyCodeine AllergyDental AnestheticsLatex AllergyPenicillin AllergyTetracycline AllergySulfa Drug AllergyOther 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:

Monday	9:00 am to 6:00 pm
Tuesday	8:00 am to 4:00 pm
Wednesday	8:00 am to 6:00 pm
Thursday	8:00 am to 5:00 pm
Friday	7:30 am to 12:00 pm

Michele Shely Horton, DDS

Ellena Kontos Vranas, DDS

Michele Shely Horton, DDS

Michele Shely Horton, DDS

Ellena Kontos Vranas, DDS

New Patient Child Registration

Patient Information

Health Information

Dental History

Person Responsible For Payment

Credit Card Authorization (optional)

Insurance Information

Primary

Secondary

Consent for Services

OFFICE LOCATION & MAP

OFFICE HOURS

HORTON & VRANAS, D.D.S.

TREATMENTS OFFERED