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Child New Patient Intake Form

Welcome!

We are delighted that you have contacted us regarding your child’s dental needs.

The decision to choose a new dentist is not easily made. Sometimes it seems like the more you read the more confusing things become.

Natural Dentistry from the Start

A holistic lifestyle is a conscious choice to make healthier decisions, and we believe your little ones can benefit greatly from holistic pediatric dentistry from the beginning. Our child friendly team at Integrative Dental Solutions understand that the condition of your child’s oral health extends far beyond just pretty teeth. It also plays an important role in their speech, breathing, mouth and jaw development, growth, behavior, confidence level, systemic health and more.

What is a Kid's Holistic Dentist?

Natural Dentistry from the Start A holistic dentist (also called a biological or natural dentist) understands the mouth-body relationship and operates according to the belief system that oral health is fundamentally connected to overall health. When it comes to children, the philosophy is the same. At Integrative Dental Solutions, it is our mission to treat and restore the natural health of your child’s mouth while working in harmony with their entire body. If we identify a problem, it is our goal to find the least invasive approach to healing while utilizing the most advanced technology known to dentistry. We offer personalized, gentle dental care for infants, toddlers, children and teens. We are advocates of minimally invasive dentistry and always use safe, non-toxic, biocompatible dental materials. Our wide range of pediatric dental services include ozone and air abrasion treatment of cavities, biocompatible dental treatments, silver diamine fluoride treatments, Vivos therapeutics, HealthyStart orthodontics, low dose digital x-rays, metal free restorations and more.

What Sets Us Apart?

Safe, Biocompatible Dental Fillings

As biological dentists, the team at Integrative Dental Solutions is committed to using safe, non- toxic biocompatible dental materials. We strictly oppose the use of amalgam, or mercury fillings, which are toxic to both children and adults. Our metal free, tooth colored composite resin fillings are safe, strong and offer a more natural looking alternative to amalgam.

Ozone and Air Abrasion

We offer the latest technology in Ozone therapy to treat oral infections in children using only water and oxygen. This ozone gas is a powerful antimicrobial agent, killing bacteria on contact and penetrating areas deep below the gum line where disinfectant or antibiotic cannot reach. Combined with Air Abrasion, also known as “drill-less” dentistry, we can treat the early stages of tooth decay in children. Air Abrasion is noiseless, heat-less and a minimally invasive alternative to drilling.

Children & Infant Tongue Tie Release

In children, tongue ties can cause difficulties with speech, eating, breathing and sleeping. When the tongue is tethered closely to the mouth and cannot move properly, it can be difficult for the child to speak clearly. He or she may experience issues with articulation or the pronouncing certain words, especially plosive sounds like “s” and a lisp may develop.

Often, a child with a tongue tie is not able to properly place their tongue on the roof of their mouth, which can lead to jaw formation problems, teeth crowding and breathing difficulties. In some cases, the tongue’s limited range of motion can lead to teeth decay because the child is not able to properly keep the teeth clean. Early detection and correction is key to preventing these problems from becoming more serious as children get older. Tongue ties are corrected with a frenectomy. A frenectomy is a minor surgery to loosen or remove the frenulum tissue, allowing the tongue to move more freely, have a wider range of motion and recover their optimal oral health.

Silver Diamine Treatments

Treating your child’s teeth with Silver Diamine is a safe and effective way to stop cavities from worsening and protect against future tooth decay. Silver Diamine is a liquid that is applied topically to your child’s teeth, making it a non-invasive and pain free method of treatment to stop cavity growth until a more permanent restoration can be put into place. To learn more about this unique service and how it can stop decay in its tracks, contact us today.

HealthyStart System

The HealthyStart System is a non-invasive, pain-free approach to opening the airway and straightening teeth without braces. The HealthyStart System consists of a series of appliances that address symptoms of Sleep Disordered Breathing. These symptoms often go misdiagnosed or untreated and worsen with age. HealthyStart aims to address these symptoms early-on so that they can be solved naturally. The HealthyStart program can correct an overbite, overjet, rotation, crowding, spacing, and align the joints for TMJ treatment.

Symptoms to look out for include:

  • Snoring and/or mouth breathing
  • Swollen tonsils or adenoids
  • Tooth Decay
  • Bed wetting
  • Low IQ and/or academic challenges Delayed or arrested growth
  • Chronic allergies and/or asthma Eczema
  • Depression and anxiety
  • Fatigue
  • Obesity
  • ADD/ADHD

Protecting and Promoting Good Health

While a healthy diet helps to promote good oral health, nothing is quite as important as training your child to properly brush and floss. Gentle brushing should start as soon as the first tooth breaks the surface. As your child’s baby teeth begin to erupt, brushing becomes increasingly important. Dr. Supriya K Shetty and our staff can help show you how to make brushing fun for your little ones. Even with good eating habits and proper brushing and flossing, cavities in baby teeth can still occur. For some young ones, tooth decay may happen more frequently due to their genetics. Treatment of cavities is yet another opportunity for you to make a healthy and holistic choice to help your child. At Integrative Dental Solutions, we want what is best for you and your entire family. It is of primary importance that overall health be valued as highly as oral health. Dr. Supriya K Shetty and the rest of our team will continue to make it our mission to help you and your young ones make healthy decisions to achieve and maintain healthier, stronger, beautiful smiles that last a lifetime.

Developing Healthy Habits

We are often asked how soon dental treatment should start. The American Academy of Pediatric Dentistry recommends beginning oral hygiene and care within six months after the first tooth erupts. While an exact age may vary, it’s never too early to introduce your young one to healthy habits that can support and encourage healthier teeth. A primary factor in helping your little one develop good oral health is snacks. Frequent snacking fuels little ones throughout the day, but snacks full of carbs and sugar can start to build up plaque and attack developing primary or baby teeth. Instead, encourage healthy snacks like fresh fruits and veggies, cheese sticks or nuts. Replacing sugary drinks or fruit juices with water also encourages the development of healthy habits.

Office Philosophy

Before we get started, it is important that you understand our philosophy of dental practice. In dental school, dentists are trained to see the patient as a “set of teeth”, and, with the exception of serious medical conditions, formulate treatment plans regardless of the needs of the patient. We see your mouth as the key to your health. Gum infections, tooth loss & decay, incompatible filling materials- even an unattractive smile, can lead to less than optimal health.

Your child’s first appointment in our office will start with a dental cleaning and x-rays with our hygienist and a comprehensive examination with the Doctor. At that time your child’s Doctor will meet with you to determine your exact needs and wants for your child. Whether you are interested in conventional, high quality dentistry, or are considering a biological/holistic approach, the doctors will formulate a treatment plan that is just right for your child.

A word about amalgam (silver/mercury fillings)-

Our office has been “Mercury Free” for over 15 years and “Mercury SAFE” for over 10 years. With the availability of superior restorative materials and the controversy about Mercury toxicity, Our Dentists feel that placing Amalgam fillings is not in the best interest for their patients.This position is contrary to that of the American Dental Association and the mainstream dental profession.If you have any concerns about the services we offer, we urge you to ask questions or seek a second opinion.

A word about education

Until 2007, Wisconsin was one of the only a handful of states that had no requirements for Continuing Education. Sadly, surveys showed that a majority of Wisconsin dentists did not attend post graduate

About our Fees –

education on a regular basis. Our Dr’s here attend numerous hours of education annually to keep up A holistic dental practice faces many challenges; maybe one of the biggest is how to make this type of with the latest techniques and materials in dentistry. Hundreds of hours of continuing education, specialized equipment and supplies, aswell as the need to spend more time with each patient each contribute to making holistic dentistry more expensive. We have worked very hard to be as efficient as possible. By using technology such as CEREC (CAD/CAM) and by completing either a quadrant or half of the mouth in one sitting, we are able to keep our fees competitive with conventional dentistry. Please remember, the quest for oral health will requirea financial commitment on your part, but it will be worth it!

In order to serve you better, we need to know a little more about you.

Canceled and Failed Appointment Policy

Your Dr. is committed to providing their patients with quality dental care. We realize the importance of your time and do everything possible to not keep you waiting. We also ask that you value the time of your Dr. and our team.

Proper notice for canceled appointments must be given to our office in order to serve all of our patients. When given proper notice, we are able to contact patients who are trying to get an appointment in our office.

Appointment reminder calls are only a courtesy. It is YOUR responsibility to write down and keep track of your scheduled appointments. If for some reason our office is not able to confirm your appointment and you do not show for a scheduled appointment, you will be assessed a “Failed Appointment Fee”.

Our office must receive no less than 2 business day notice It is YOUR when canceling an appointment (5 business days for surgical appointments). Messages left on our answering machine after hours canceling an appointment for the following day, or over the weekend (Sat., Sun.) canceling an appointment for the following Monday, are not acceptable.Please note that we are in the office Mondays from 8am to 4pm, Tuesday – Thursday 8am – 3pm and Fridays 8am-2pm.

The fees for failed appointments or appointments canceled without proper notice are:

Doctor and Specialized Hygiene appointments- 10% of the Total cost of the appointment

Oral Surgeon/Anesthesiology appointments- 50% of the Total cost of the appointment

Hygiene Dental Hygiene appointments - $50.00 non-refundable pre-payment required for next appointment

Office Financial Policy

Your Dr. has formulated a treatment plan that will restore your mouth to optimal health. Quality dentistry is initially more expensive, but by using a comprehensive, “do it right the first time” approach, we can save you unnecessary discomfort and expenses in the future. And, by implementing the policies below, we are able to keep our fees as low as possible.

Our goal is to make quality dental care affordable for you!

To reserve your appointment, financial arrangements must be made at the time of scheduling

Option 1 - Pre-Payment: for the pre-payment of entire proposed treatment plan (some exclusions may apply). Payment is due at the time of scheduling.

  • 5% Discount (using check or cash)
  • 3% Discount with credit card

Option 2 - Financing:

  • CareCredit Financing- 1 year deferred interest for transactions over $200.

You can apply for CareCredit here in the office without the need for additional forms. This can be done electronically or with a short phone call.If you plan on using CareCredit please note that your application must be approved before scheduling.

Option 3 - Pay as you go:

  • 30% deposit due at the time of scheduling, the remaining balance to be paid on appointment day.

Refunds:

If payment is made by credit card and a refund is requested, a 3% credit card processing fee will be deducted from the refund. All refunds will be returned through the mail in the form of a check.

If you have insurance:

  • We do not accept assignment of insurance benefits
  • We are not in-network with any insurance plan
  • We do not submit pre-treatment estimates
  • We will submit a claim on your behalf the day of service

Your insurance company has 30 days to pay the claim and payment is sent to you. We include all information for your insurance company to handle your claim without delay (i.e. narrative, x-rays and pictures)

Finally - there is a $50 fee for all returned checks.

I have read, understand and agree to the above policies.

If You Have Insurance

As a courtesy and convenience to you, we will file your dental insurance claim for you. This claim will include everything your insurance company requires to process the claim (Including pictures, x-rays and a narrative if necessary). In order for you to be promptly reimbursed by the insurance company, the claim process is computerized and claims are sent out within a day or two of service. Note – being computerized allows us to attach copies of x-rays and pictures with the initial claim (rather than waiting for the insurance company to request them). This greatly expedites the claim handling process.

It is extremely important that you understand the following:
  1. Our office is not an insurance driven practice, we choose not participate with insurance companies as we do not want our patient care to be dictated by them. Therefore, all communication with your insurance company is your responsibility including claim status checks.
  2. Your insurance company has been given all the information necessary to process your claim and should not have to request more information.
  3. UCR (Usual, customary and reasonable) fees may vary by as much as 300%! They do NOT represent average fees for this area; rather, they reflect what your insurance company is able or willing to pay.
  4. While we present a treatment plan that best restores your mouth to health, the insurance company will usually only pay for the least expensive available treatment.
  5. Some procedures, such as inlays or onlays may not be covered by insurance.
  6. Because maximum benefits in dental insurance plans have not increased in 50 years (really!), the are usually inadequate for anything other than maintenance or preventive type treatments.
  7. By law, your claim must be paid or rejected after 30 days, therefore, if your insurance company has not paid on your claim after 30 days, regardless of the reason, contact your insurance company immediately!

Remember, we are looking out for your best interest - the insurance company is looking out for theirs!

I have read and understand the above.

Patient Consent for Use of Electronic Mail (e-Mail)

  1. Risk of using Email

    2. Our practice offers patients the opportunity to communicate with clinicians by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before giving consent. These risks include, but are not limited to:

    1. E-mail can be circulated, forwarded, and stored in numerous paper and electronicfiles.
    2. E-mail can be immediately broadcast worldwide and be received by both intended and unintended recipients.
    3. E-mail senders can misaddress e-mail.
    4. E-mail can be more easily falsified than handwritten or signed documents. e. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
    5. Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
    6. E-mail can be intercepted, altered, forwarded or used without authorization or detection
    7. E-mail can be used to introduce viruses into computer systems.
    8. E-mail can be used as evidence in court.
  2. Conditions for the use of e-mail

    3. Our practice will use reasonable means to protect the security and confidentiality of e- mail information sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by provider’s intentional misconduct. Thus, patients must consent to the use of e-mail for patient information.

    Consent to the use of e-mail includes agreement with the following conditions:

    1. All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s dental and medical record. Because they are a part of the dental and medical record, other individuals authorized to access the dental and medical record, such as staff and billing personnel will have access to those emails.
    2. We may forward emails internally to our staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. Our practice will not, however, forward emails to independent third parties without the patients prior written consent, except as authorized or required by law.
    3. Although we will endeavor to read and respond promptly to an e-mail from the patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for dental and medical emergencies or other time sensitive matters.
    4. If the patient’s email requires or invites a response from us and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond.
    5. The patient should not use e-mail for communication regarding sensitive dental and medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, issues of abuse, developmental disability, or substance abuse.
    6. The patient is responsible for informing our practice of any types of information the patient does not want to be sent by email, in addition to those set out in (item e) above.
    7. The patient is responsible for protecting his/her password or other means of access to email. Our practice is not liable for breaches of confidentiality caused by the patient or any third party.
    8. Our practice shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
    9. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
  3. Instructions

    4. To communicate by email the patient shall:

    1. Limit or avoid use of his/her employers computer.
    2. Inform our practice of changes in his/her email address.
    3. Put his/her name in the body of the e-mail.
    4. Include the category of the communication in the emails subject line, for routing purposes (e.g. billing question)
    5. Review the email to make sure it is clear and that all relevant information is provided before sending to provider.
    6. Inform us that the patient recieved email from our practice
    7. Take precautions to preserve the confidentiality of emails, such as using screen savers and safeguarding his/her computer password.
    8. Withdraw consent only by e-mail or written communication to Provider.

PATIENT ACKNOWLEDGMENT AND AGREEMENT

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between Provider and me, and consent to the conditions outlined herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by email. Any questions I may have had were answered.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (MM/DD/YR), and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x- rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $30 and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Integrative Dental Solutions
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

I have recieved a copy of this office's Notice of Privacy Practices.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

  • Individual refused to sign
  • Communications barriers prohibited obtaining the acknowledgement
  • An emergency situation prevented us from obtaining acknowledgement
  • Other

  • (Please Specify)



© 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

QUESTIONS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U. S. Department of Health and Human Services.

Contact Officer: Dr. Supriya Shetty

Telephone: Pewaukee 262.691.4555
Fax: 262.691.4579

E-mail: info@winaturaldentist.com

Address: 23770 Capitol Dr., Pewaukee, WI 53072

Directions to Our Pewaukee Office

We are located in the Five Fields Plaza at 23770 Capitol Drive in Pewaukee, WI – at the intersections of Capitol Drive (190) and Highfield Drive.LOCATED IN THE BACK OF THE BUILDING

Please call office with any questions: 262-691-4555

When using GPS enter: Highfield Dr. Pewaukee WI.

Places To Eat:

We are just a short drive from numerous eateries such as Thunder Bay Grill, Applebee’s or Panera’s, About 10 minutes away is Good Harvest Market (www.goodharvestmarket.com) an organic food store with café and lunch menu.

Places To Stay:

Wildwood Lodge 262.506.2000

Holiday Inn 262.506.6300

Healthy Start Questionnaire

Snoring:
Grinds teeth:
Sweating in sleep:
Mouth breathing during day/night:
Stops breathing at night:
Hyperactive:
Headaches:
Allergies:
Poor school performance:
Wakes up at night:
Attention deficit:
Sleepy and irritable:
Wets the bed:
Feels sad or depressed:
Speech problems:
Sucks thumb/fingers:

To be completed by dentist: At Risk Not at Risk



Five Fields Plaza
N35 W23770 Capitol Drive
Pewaukee, WI 53072
262-691-4555

New Patient Questionnaire

Please take the time to answer our new patient questionnaire, this helps us to understand why you have chosen our holistic dental office and what your expectations are so we can better assist and meet your needs.

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Child Registration Form

Sex
Marital Status
Method of Payment:

Dental Insurance 1st Coverage

Dental Insurance 2nd Coverage

CONSENT:

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care oper­ations that are related to treatment or payment.

I consent to the disclosure of my records (or my child's records) to the following per­sons who are involved in my care (or my child's care) or payment for that care.

My consent to disclosure of records shall be effective until I revoke it in writing.

I authorize payment directly to the dentist or dental group of insurance benefits other­wise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am finan· cially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for pay­ment of services not paid, by my dental care payor.

I attest to the accuracy of the information on this page

DENTAL HISTORY - SELECT THE APPROPRIATE ANSWER

Wakes up at night:
Were any x-rays or radiographs taken when your child previously visited the dentist?
Does your child eat between meals?
Does your child eat sweets, such as candy, soda pop, chewing gum?
When does your child brush his/her teeth?
How does your child receive fluoride?
Have any cavities been noted in the past?
Does your child suck his/her thumb or fingers?
Were any teeth (baby or permanent) removed by extraction?
Was it suggested that the space be maintained
Was an appliance placed
Have there been any injuries to teeth, such as falls, blows, chips, etc?
Has your child had any problem with dental treatment in the past?
Has anyone in the family, including parents, had orthodontics?
Has your child ever received a local anesthetic?
Has your child ever had occlusal sealants?
Does your child think there is anything wrong with his/her teeth?

Medical History

Does your child have a health problem?
Is your child under care of physician?
Is your child receiving any medication?
Is your child allergic to penicillin, antibiotics or other drugs?
Is your child allergic to or sensitive to any metals or latex?
Does your child have other allergies?
Does your child have other allergies?
Has your child ever had surgery?
Does your child have a heart murmur?
Is surgery contemplated?
Does your child experience severe or prolongated bleeding?
Does your child have AIDS or has he/she tested HIV positive?
Has your child tested positive for hepatitis?
Is your child subject to nervous disorders?
Which disorders?
Does your child have frequent headaches?
Has your child had history of

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue