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107 W Robertson St, Brandon, FL 33511

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(813) 685-0804
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(813) 685-0804
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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 Dentistry
Tell Us About Your Child
Today's Date:*
Date Format: MM slash DD slash YYYY
Child's Name:*
First Last
Nickname:
Gender*
- Male
- Female
Child's Birthdate:*
Date Format: MM slash DD slash YYYY
Child's Age:
School
Grade
Child's Home #:
S.S. #:
Child's Home Address:*
Street Address City State ZIP Code
Email:

Who is Accompanying the Child Today?
Name*
First Last
Relation:
Do you have legal custody of the child?*
- Yes
- No
Whom may we THANK for referring you:
Other Children in family (Names & Ages)
Name Age
Are you currently patients here:
- Yes
- No
Previous/Present Dentist:
Last visit date:
Date Format: MM slash DD slash YYYY

Person Responsible for Account
Mother's Information:
- STEP MOTHER
- GUARDIAN
Name:*
First Last
Date of Birth:*
Date Format: MM slash DD slash YYYY
Address:*
Street Address City State ZIP Code
For How Long?
Employed By:
For How Long?
Occupation:
SS#:*
Drivers License #:*
Business Phone:
Home Phone:
Father's Information:
- STEP FATHER
- GUARDIAN
Name:*
First Last
Date of Birth:*
Date Format: MM slash DD slash YYYY
Address:*
Street Address City State ZIP Code
For How Long?
Employed By:
For How Long?
Occupation:
SS#:*
Drivers License #:*
Business Phone:
Home Phone:

Primary Dental Insurance
Insurance Co. Name:
Insurance Co. Address:
Street Address City 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?
- Yes
- No
Do you have secondary dental insurance?
Secondary Dental Insurance
Insurance Co. Name:
Insurance Co. Address:
Street Address City 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?
- Yes
- No

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?
- Yes
- No

Why did you Bring the Child to the Dentist Today?
Please explain why you brought the child today
Has the child ever had a serious/difficult problem associated with previous dental work?
- Yes
- No
Is the child's water fluoridated?
- Yes
- No
Is the child taking fluoridated vitamins?
- Yes
- No
Has the child ever had any pain-tenderness in their jaw joint (TMJ-TMD)
- Yes
- No
Does the child brush their teeth daily?
- Yes
- No
Floss their teeth daily?
- Yes
- No
Child's Physician:
Phone #:
Last Visit Date:
Date Format: MM slash DD slash YYYY
Is the child currently under the care of a physician?
- Yes
- No
Describe the child's current health:
- Good
- Fair
- Poor
Please 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 Treat
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.
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.
Name Date 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:
Name Phone (###) ###-#### Relationship
*
Signature of Legal Guardian(s)
*
Date Format: MM slash DD slash YYYY

Date
Relationship 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

Privacy Policy
Disclaimer
Site Map

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Under the advice of the American Dental Association (ADA), our offices are closed except for emergencies and urgent treatment needs. We will reach out to you directly to reschedule any appointments that will be affected by our closure. If there is a dental emergency, please call our office number and one of our emergency team members will assist you.

More Information

Name	Age

Name	Date of Birth (mm/dd/yyyy)

Name	Phone (###) ###-####	Relationship

Step 1 of 11

Welcome

Tell Us About Your Child

Who is Accompanying the Child Today?

Person Responsible for Account

Primary Dental Insurance

Secondary Dental Insurance

Has the Child ever had the Following Medical Problems?

Why did you Bring the Child to the Dentist Today?

Does the Child have the Following Habits

Permission to Treat

HIPAA FORM

Pediatric Dentistry of Brandon, PA

Important Dental Insurance Information