American Canyon Pediatric Dentistry Patient Form
This form is designed for new patients and makes it easier for them to arrive at their first appointment.
Content
PATIENT INFORMATION
Child’s Full Name:______________________________________________________________Name child goes by:_________________________________
□M □F
Date of Birth:__________________________________________ Age:_______________________________
Address:_____________________________________________________________ City/State: _____________________________________ Zip:______________________
Home Number: ______________________________________________
Current School:_________________________________ Grade:_________ Hobbies:________________________________________________
Please list any other siblings seen in this office:
__________________________________________________________
Who may we thank for referring you to us?
PARENT/LEGAL GUARDIAN (LG) INFORMATION
Parent/LG Name
Relationship to Patient: _______________________________________
Date of Birth:_________________________________________________________________________ SSN:________________________________________________________________________
Address (if different than patient):______________________________________________________________________________________________________________________________
Employer:__________________________________________________ Work #:______________________________________________ Cell #________________________________________
Primary E-mail:_______________________________________________________________________________________________
Parent/LG Name: ________________________________________________________________________________ Relationship to Patient: ___________________________________
Date of Birth:____________________________________________________________________________ SSN:____________________________________________________________________
Address (if different than patient):____________________________________________________________________________________________________________________________
Employer:__________________________________________________ Work #:____________________________________________ Cell #_________________________________________
Primary E-mail:_______________________________________________________________________________________________
DENTAL INSURANCE
Policy Holder:______________________________________________________________ SSN:_____________________________________ DOB:__________________________________________
Insurance Company:___________________________________________________________________________
Group Number:_________________________________________________
EMERGENCY CONTACT (other than parents/guardians listed above)
Contact Name: ____________________________________________________ Relationship: ____________________________ Contact Number: _______________________________________
Contact Name:_______________________________________________________Relationship:_____________________________Contact Number:_______________________________________
PATIENT NAME: ____________________________________________________________________________________________ DATE: ___________________________________________________
HEALTH HISTORY
□YES
□NO
Physician/Phone#: _______________________________________________________
Is your child current on immunizations:
Please list any medications your child is currently taking:
Please list any allergies (including medication allergies):
______________________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________
YES
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
YES
ADHD/ADD
Anemia
Anxiety/Depression
Asthma
Autism/Asperger’s
Cerebral Palsy
Chronic Sinusitis
Deaf/Blind
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
YES
Developmental Delays
Diabetes
Down Syndrome
Epilepsy/Seizures
Fainting
Heart Problems
Heart Murmurs
HIV/AIDS
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
Kidney/Bladder Disease
Liver Disease/Hepatitis
Malignancies
Rheumatoid Arthritis
Sensory Issues
Speech Delays
Thyroid Problems
Tuberculosis
Please list any surgeries or hospitalizations: ________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
Additional medical information:_________________________________________________________________________________________________________________________________
DENTAL HISTORY
YES
NO
YES
NO
Is this your child’s first dental visit?
If not, date of last visit:__________________________
Were X-rays taken? _____________________________
Does your child have any habits? (thumb sucking, pacifier,
etc) If so, list:__________________________________________________
Has your child had a bad experience in a
dental office?
Does your child drink juice or soda? If so, how much a day?
__________________________________________________________________
Did your child nurse or use a bottle after 12
months?
Does your child snack frequently during the day?
Did/does your child nurse or have a bottle during
the night?
Has your child had a toothache or any type of oral pain
recently?
Do you assist your child’s brushing?
How often do they brush:________________________
________________________________________________________
Has your child ever had a dental injury (bumped or
chipped tooth, bruised lip)?
Explain:________________________________________________________
________________________________________________________________
Type of water source?
□Private Well
□City Water System
Purpose of today’s visit?________________________________________________________________________________________________
To the best of my knowledge, the answers I have given are accurate. I understand it is important to report changes in my child’s
medical or dental status to the dentist, and I agree to do so. I give permission to the dentist to obtain additional information from my
child’s physician regarding medical history needed to provide dental treatment.
_______________________________________________________________________________
Signature of Parent/Legal Guardian
________________________________
Date
MISSED APPOINTMENTS/LATE CANCELLATIONS
Broken appointments and late arrivals represent a cost to us, to you and to other patients who could have been
seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment.
FINANCIAL POLICY
If you have dental insurance, we will be happy to file your claim for you. You will be responsible for your co-payment
at each appointment. If you do not have dental insurance, payment for professional services is due at the time
dental treatment is provided. Please bring your dental insurance card to every visit. You must be familiar with your
insurance benefits. By law, your insurance company is required to pay each claim within 30 days of receipt. PLEASE
UNDERSTAND that we file dental insurance as a courtesy to our patients. We are not responsible for how your
insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating
your portion of the cost of treatment.
We currently are only providers with Delta Dental Insurance. We accept, but are an out-of-network provider for all
other PPO's and Preferred Options. We DO NOT take HMO/DMO/PMI, or any MediCal/Healthy Families. Cash Patients
will be required to pay in full when services are rendered.
Fact 1 - NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay
more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for
coverage or the type of contract your employer has set up with the insurance company. For non-preventive dental
treatment, we will ask you to pay 20% of the treatment at the time the service is rendered.
Facts 2 - BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the
dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your
dentist's fee exceeds the usual, customary, or reasonable fee ("UCR") used by the company. A statement such as
this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or
well above what most dentists in the area charge for a certain service. This can be very misleading and simply is
not accurate. Insurance companies set their own schedules and each company uses a different set of fees they
consider “reasonable.”
We accept cash, personal checks, and most major credit cards. There is a $25.00 service charge for all returned
checks. If it becomes necessary to forward your account to a collection agency, you will be responsible for the fee
charged by the collection agency for costs of collections in addition to the amount of the bill. If your account goes
into collections at any time all future visits must be paid in full with cash or credit card at the time of the visit.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company
address, or a change of employment.
Follow-up Dental Care
No healthcare provider can make guarantees regarding treatment success. We feel that in order to increase your
child/children's chances of long term success you must follow-up with regular check-ups every six months,
completed proposed treatment, brush twice a day and floss. In doing this you are giving your child/children the best
possible opportunity to achieve long-term health.
Signature of Parent/Guardian _______________________________________________ Date _______________
Child/Children’s Name ______________________________________________________________________________
Informed Consent For General Dental Procedures
As the patient’s parent/legal guardian you have the right to accept or reject dental treatment
recommended by the dentists at American Canyon Pediatric Dentistry. Prior to consenting to
treatment, you should carefully consider the anticipated benefits and commonly known risks of the
recommended procedure, alternative treatments and the option of no
treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks, and complications
with your child’s dentist and all of your questions are answered. By consenting to the treatment,
you are acknowledging your willingness to accept known risks and complications, no matter how
slight the probability of occurrence.
It is very important that you provide Dr. Rochelle Manangkil with accurate information before, during,
and after treatment. It is equally important that you follow Dr's. advice and recommendations
regarding medication, pre and post treatment instructions, referrals to other dentists or specialists,
and return for scheduled appointments. If you fail to follow their advice, you may increase the
chances of a poor outcome.
Please read and initial the items below and sign at the bottom of the form.
1.
Treatment to be Provided
I understand that during my child’s course of treatment the following may be provided:
examinations, preventive services (fluoride, sealants and space maintainers), restorations
(fillings), crowns and radiographs (x-rays). I will be consulted prior to each appointment.
2.
Drugs and Medications
I understand that antibiotics, analgesics, anesthetic agents and other medications can cause
allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or
anaphylactic shock (severe allergic reaction).
3.
Changes in Treatment Plan
I understand that during treatment it may be necessary to change or add procedures
because of conditions found while working on teeth that were not discovered during
examination. The most common changes are root canal therapy and extraction, following
routine restorative procedures. I give my permission to my child’s dentist to make any/all
changes and additions as necessary. I understand that I will be consulted regarding changes
whenever possible.
_______________________________
____________________
Parent’s Signature
Date
_______________________________
Child’s Name
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to
privacy regarding my child’s protected health information. I understand that this information can and will be used to:
-
Conduct, plan and direct my child’s treatment and follow–up among the multiple
healthcare providers who may be involved in that treatment directly or indirectly
-
Obtain payment from third-party payers
-
Conduct normal healthcare operations such as quality assessments and physician
certifications
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the
uses and disclosures of my child’s health information. I understand that this organization has the right to change its
Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current
copy of the Notice of Privacy Practices.
I understand that I may request, in writing, that you restrict how my child’s private information is used or disclosed
to carry out treatment, payment or health care operations. I also understand you are not required to agree to my
requested restrictions; however, if you agree then you are bound to abide by such restrictions.
I understand I have the right to revoke this consent except to the extent that we have already taken action covered
under this consent. If I chose to revoke this consent, I must do it in
writing.
Contact Information:
Patient’s Name:____________________________________________________________________ May we call you at:
Home: Yes/No
Work: Yes/No
Cell: Yes/ No
Please list persons with whom we may we discuss your child’s health information:__________________________________
__________________________________________________________________________________________________________
Please list persons to whom may we release medical information, including picking up
prescriptions:_______________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________
Signature of Parent/Guardian
________________________
Relationship
_________
Date
Child’s Full Name:______________________________________________________________Name child goes by:_________________________________
□M □F
Date of Birth:__________________________________________ Age:_______________________________
Address:_____________________________________________________________ City/State: _____________________________________ Zip:______________________
Home Number: ______________________________________________
Current School:_________________________________ Grade:_________ Hobbies:________________________________________________
Please list any other siblings seen in this office:
__________________________________________________________
Who may we thank for referring you to us?
PARENT/LEGAL GUARDIAN (LG) INFORMATION
Parent/LG Name
Relationship to Patient: _______________________________________
Date of Birth:_________________________________________________________________________ SSN:________________________________________________________________________
Address (if different than patient):______________________________________________________________________________________________________________________________
Employer:__________________________________________________ Work #:______________________________________________ Cell #________________________________________
Primary E-mail:_______________________________________________________________________________________________
Parent/LG Name: ________________________________________________________________________________ Relationship to Patient: ___________________________________
Date of Birth:____________________________________________________________________________ SSN:____________________________________________________________________
Address (if different than patient):____________________________________________________________________________________________________________________________
Employer:__________________________________________________ Work #:____________________________________________ Cell #_________________________________________
Primary E-mail:_______________________________________________________________________________________________
DENTAL INSURANCE
Policy Holder:______________________________________________________________ SSN:_____________________________________ DOB:__________________________________________
Insurance Company:___________________________________________________________________________
Group Number:_________________________________________________
EMERGENCY CONTACT (other than parents/guardians listed above)
Contact Name: ____________________________________________________ Relationship: ____________________________ Contact Number: _______________________________________
Contact Name:_______________________________________________________Relationship:_____________________________Contact Number:_______________________________________
PATIENT NAME: ____________________________________________________________________________________________ DATE: ___________________________________________________
HEALTH HISTORY
□YES
□NO
Physician/Phone#: _______________________________________________________
Is your child current on immunizations:
Please list any medications your child is currently taking:
Please list any allergies (including medication allergies):
______________________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________
YES
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
YES
ADHD/ADD
Anemia
Anxiety/Depression
Asthma
Autism/Asperger’s
Cerebral Palsy
Chronic Sinusitis
Deaf/Blind
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
YES
Developmental Delays
Diabetes
Down Syndrome
Epilepsy/Seizures
Fainting
Heart Problems
Heart Murmurs
HIV/AIDS
□
□
□
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
Kidney/Bladder Disease
Liver Disease/Hepatitis
Malignancies
Rheumatoid Arthritis
Sensory Issues
Speech Delays
Thyroid Problems
Tuberculosis
Please list any surgeries or hospitalizations: ________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
Additional medical information:_________________________________________________________________________________________________________________________________
DENTAL HISTORY
YES
NO
YES
NO
Is this your child’s first dental visit?
If not, date of last visit:__________________________
Were X-rays taken? _____________________________
Does your child have any habits? (thumb sucking, pacifier,
etc) If so, list:__________________________________________________
Has your child had a bad experience in a
dental office?
Does your child drink juice or soda? If so, how much a day?
__________________________________________________________________
Did your child nurse or use a bottle after 12
months?
Does your child snack frequently during the day?
Did/does your child nurse or have a bottle during
the night?
Has your child had a toothache or any type of oral pain
recently?
Do you assist your child’s brushing?
How often do they brush:________________________
________________________________________________________
Has your child ever had a dental injury (bumped or
chipped tooth, bruised lip)?
Explain:________________________________________________________
________________________________________________________________
Type of water source?
□Private Well
□City Water System
Purpose of today’s visit?________________________________________________________________________________________________
To the best of my knowledge, the answers I have given are accurate. I understand it is important to report changes in my child’s
medical or dental status to the dentist, and I agree to do so. I give permission to the dentist to obtain additional information from my
child’s physician regarding medical history needed to provide dental treatment.
_______________________________________________________________________________
Signature of Parent/Legal Guardian
________________________________
Date
MISSED APPOINTMENTS/LATE CANCELLATIONS
Broken appointments and late arrivals represent a cost to us, to you and to other patients who could have been
seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment.
FINANCIAL POLICY
If you have dental insurance, we will be happy to file your claim for you. You will be responsible for your co-payment
at each appointment. If you do not have dental insurance, payment for professional services is due at the time
dental treatment is provided. Please bring your dental insurance card to every visit. You must be familiar with your
insurance benefits. By law, your insurance company is required to pay each claim within 30 days of receipt. PLEASE
UNDERSTAND that we file dental insurance as a courtesy to our patients. We are not responsible for how your
insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating
your portion of the cost of treatment.
We currently are only providers with Delta Dental Insurance. We accept, but are an out-of-network provider for all
other PPO's and Preferred Options. We DO NOT take HMO/DMO/PMI, or any MediCal/Healthy Families. Cash Patients
will be required to pay in full when services are rendered.
Fact 1 - NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay
more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for
coverage or the type of contract your employer has set up with the insurance company. For non-preventive dental
treatment, we will ask you to pay 20% of the treatment at the time the service is rendered.
Facts 2 - BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the
dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your
dentist's fee exceeds the usual, customary, or reasonable fee ("UCR") used by the company. A statement such as
this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or
well above what most dentists in the area charge for a certain service. This can be very misleading and simply is
not accurate. Insurance companies set their own schedules and each company uses a different set of fees they
consider “reasonable.”
We accept cash, personal checks, and most major credit cards. There is a $25.00 service charge for all returned
checks. If it becomes necessary to forward your account to a collection agency, you will be responsible for the fee
charged by the collection agency for costs of collections in addition to the amount of the bill. If your account goes
into collections at any time all future visits must be paid in full with cash or credit card at the time of the visit.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company
address, or a change of employment.
Follow-up Dental Care
No healthcare provider can make guarantees regarding treatment success. We feel that in order to increase your
child/children's chances of long term success you must follow-up with regular check-ups every six months,
completed proposed treatment, brush twice a day and floss. In doing this you are giving your child/children the best
possible opportunity to achieve long-term health.
Signature of Parent/Guardian _______________________________________________ Date _______________
Child/Children’s Name ______________________________________________________________________________
Informed Consent For General Dental Procedures
As the patient’s parent/legal guardian you have the right to accept or reject dental treatment
recommended by the dentists at American Canyon Pediatric Dentistry. Prior to consenting to
treatment, you should carefully consider the anticipated benefits and commonly known risks of the
recommended procedure, alternative treatments and the option of no
treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks, and complications
with your child’s dentist and all of your questions are answered. By consenting to the treatment,
you are acknowledging your willingness to accept known risks and complications, no matter how
slight the probability of occurrence.
It is very important that you provide Dr. Rochelle Manangkil with accurate information before, during,
and after treatment. It is equally important that you follow Dr's. advice and recommendations
regarding medication, pre and post treatment instructions, referrals to other dentists or specialists,
and return for scheduled appointments. If you fail to follow their advice, you may increase the
chances of a poor outcome.
Please read and initial the items below and sign at the bottom of the form.
1.
Treatment to be Provided
I understand that during my child’s course of treatment the following may be provided:
examinations, preventive services (fluoride, sealants and space maintainers), restorations
(fillings), crowns and radiographs (x-rays). I will be consulted prior to each appointment.
2.
Drugs and Medications
I understand that antibiotics, analgesics, anesthetic agents and other medications can cause
allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or
anaphylactic shock (severe allergic reaction).
3.
Changes in Treatment Plan
I understand that during treatment it may be necessary to change or add procedures
because of conditions found while working on teeth that were not discovered during
examination. The most common changes are root canal therapy and extraction, following
routine restorative procedures. I give my permission to my child’s dentist to make any/all
changes and additions as necessary. I understand that I will be consulted regarding changes
whenever possible.
_______________________________
____________________
Parent’s Signature
Date
_______________________________
Child’s Name
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to
privacy regarding my child’s protected health information. I understand that this information can and will be used to:
-
Conduct, plan and direct my child’s treatment and follow–up among the multiple
healthcare providers who may be involved in that treatment directly or indirectly
-
Obtain payment from third-party payers
-
Conduct normal healthcare operations such as quality assessments and physician
certifications
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the
uses and disclosures of my child’s health information. I understand that this organization has the right to change its
Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current
copy of the Notice of Privacy Practices.
I understand that I may request, in writing, that you restrict how my child’s private information is used or disclosed
to carry out treatment, payment or health care operations. I also understand you are not required to agree to my
requested restrictions; however, if you agree then you are bound to abide by such restrictions.
I understand I have the right to revoke this consent except to the extent that we have already taken action covered
under this consent. If I chose to revoke this consent, I must do it in
writing.
Contact Information:
Patient’s Name:____________________________________________________________________ May we call you at:
Home: Yes/No
Work: Yes/No
Cell: Yes/ No
Please list persons with whom we may we discuss your child’s health information:__________________________________
__________________________________________________________________________________________________________
Please list persons to whom may we release medical information, including picking up
prescriptions:_______________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________
Signature of Parent/Guardian
________________________
Relationship
_________
Date
