Step 1 of 11 9% This form is securely transmitted via an encrypted connection to PatientPrism.com which is an SSL secured and HIPAA compliant form solution. It is our practice policy that every patient is accompanied by a Parent or Legal Guardian for the First Visit. Legal guardians, including adoptive or step-parents, must bring along paperwork which establishes legal guardianship so we may keep a copy in the patient’s file. If a Parent or Legal Guardian will not be able to attend the first visit, please contact us so we may reschedule the appointment or to consider additional options. Welcome PEDIATRIC DENTISTRY OF BRANDON Jorge O. Torres, DDS & Associates Specialists in Pediatric DentistryTell Us About Your ChildToday's Date:* Date Format: MM slash DD slash YYYY Child's Name:* First Last Nickname:Gender*MaleFemaleChild's Birthdate:* Date Format: MM slash DD slash YYYY Child's Age:SchoolGrade1st2nd3rd4th5th6th7th8th9th10th11th12thChild's Home #:S.S. #:Child's Home Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email: Who is Accompanying the Child Today?Name* First Last Relation:Do you have legal custody of the child?*YesNoWhom may we THANK for referring you:Other Children in family (Names & Ages)NameAge Are you currently patients here:YesNoPrevious/Present Dentist:Last visit date: Date Format: MM slash DD slash YYYY Person Responsible for AccountMother's Information:STEP MOTHERGUARDIANName:* First Last Date of Birth:* Date Format: MM slash DD slash YYYY Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For How Long?Employed By:For How Long?Occupation:SS#:*Drivers License #:*Business Phone:Home Phone:Father's Information:STEP FATHERGUARDIANName:* First Last Date of Birth:* Date Format: MM slash DD slash YYYY Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For How Long?Employed By:For How Long?Occupation:SS#:*Drivers License #:*Business Phone:Home Phone: Primary Dental InsuranceInsurance Co. Name:Insurance Co. Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Co. Phone:Group #,(plan, Local, or Policy #)Insured's Name: First Last Relationship to patient:Insured's Birthday Date Format: MM slash DD slash YYYY SS#:Insured's Employer:Orthodontic coverage?YesNoDo you have secondary dental insurance?YesNoSecondary Dental InsuranceInsurance Co. Name:Insurance Co. Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Co. Phone:Group #,(plan, Local, or Policy #)Insured's Name: First Last Relationship to patient:Insured's Birthday Date Format: MM slash DD slash YYYY SS#:Insured's Employer:Orthodontic coverage?YesNo Has the Child ever had the Following Medical Problems? Heart Murmur Cancer Diabetes Rheumatic Fever HIV+-AIDS Hemophilia Asthma Hepatitis Tuberculosis Congenital Heart Defect Convulsions-Epilepsy Abnormal Bleeding Hearing Impairment Any Operations Any stays in a hospital Kidney-Liver Problems Handicaps-Disabilities Allergies to any drugs Has your physician ever advised you that your child should be premedicated with antibiotics before dental treatment?YesNo Why did you Bring the Child to the Dentist Today?Please explain why you brought the child todayHas the child ever had a serious/difficult problem associated with previous dental work?YesNoIs the child's water fluoridated?YesNoIs the child taking fluoridated vitamins?YesNoHas the child ever had any pain-tenderness in their jaw joint (TMJ-TMD)YesNoDoes the child brush their teeth daily?YesNoFloss their teeth daily?YesNoChild's Physician:Phone #:Last Visit Date: Date Format: MM slash DD slash YYYY Is the child currently under the care of a physician?YesNoDescribe the child's current health:GoodFairPoorPlease list all drugs that the child is currently taking: Please list all drugs-latex that the child is allergic to: Does the Child have the Following Habits Thumb-Finger Sucking Lip Sucking-Biting Nail Biting Nursing Bottle Habits Pacifier Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. I understand 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 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 my child may need and I am responsible for the cost of this treatment at the time of visit unless prior arrangements have been made.Signature of parents or guardian* Permission to TreatIt is our practice policy that every patient is accompanied by a Parent or Legal Guardian for the First Visit. Legal guardians, including adoptive or step-parents, must bring along paperwork which establishes legal guardianship so we may keep a copy in the patient’s file. If a Parent or Legal Guardian will not be able to attend the first visit, please contact us so we may reschedule the appointment or to consider additional options.I (We)*name(s) of legal guardian(s)authorize Pediatric Dentistry of Brandon, PA and its personnel to deliver dental services to my child(ren), listed below. NameDate of Birth (mm/dd/yyyy) I (We) authorize the following people to bring my child(ren) in for treatment, and/or to contact in case of an emergency:NamePhone (###) ###-####Relationship *Signature of Legal Guardian(s)* Date Format: MM slash DD slash YYYY DateRelationship to Patient:Primary Phone: HIPAA FORM I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company); The day-to-day healthcare operations of this practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I may revoke this consent in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Signed* Date Format: MM slash DD slash YYYY Patient Name* First Last Relationship to Patient:Signature:*Pediatric Dentistry of Brandon, PA Important Dental Insurance Information Understanding your insurance benefits can be quite challenging. Our goal is to assist you in obtaining your maximum dental benefits. We care for patients whose parents or legal guardians are employed by hundreds of different companies. Each company pays an insurance premium for specific coverage, which fits each employer's budget for the year. Traditionally, these coverages can change from year to year. They do not notify us of any changes in your specific policy. It is absolutely necessary that you become familiar with your network, policy, exclusions, deductibles and required co-pays. For instance, some insurance companies do not cover white fillings, some companies have age restrictions, etc. You will be asked to approve all treatment your child may need. It will be your responsibility to cover all payment differences between the office fee and the amount of your insurance reimbursement. I hereby authorize Pediatric Dentistry of Brandon, PA, to release to my insurance company any information acquired in the course of my child's dental care. I hereby authorize benefits to be paid directly to Dr. Jorge Torres and Pediatric Dentistry of Brandon, PA. I understand that I am responsible for any unpaid balance. *Signature of Parent or Legal Guardian authorizing treatment* Date Format: MM slash DD slash YYYY Date
