Patient Information and Health History Form

PATIENT INFORMATION

Patient Name:
Name to be called:
Date of Birth:
SSN:
Gender:
Mailing Address:
City:
State:
Zip:
Home Phone:
Mom's Cell:
Dad's Cell:
Hobbies and Interests:
Whom may we thank for referring you?

PARENT’S INFORMATION

Guardian I

Name:
Date of Birth:
SSN:
Relationship to Patient:
Marital Status:
Home Phone:
Cell Phone:
Email Address:
How may we contact you? (check all that apply):
Check box if mailing address is the same as the patient's listed above.
Mailing Address:
City:
State:
Zip Code:
Employer:
Work Phone:
ext.

Guardian II

Name:
Date of Birth:
SSN:
Relationship to Patient:
Marital Status:
Home Phone:
Cell Phone:
Email Address:
How may we contact you? (check all that apply):
Check box if mailing address is the same as the patient's listed above.
Mailing Address:
City:
State:
Zip Code:
Employer:
Work Phone:
ext.
Who has LEGAL custody of patient?
Who does the patient live with?
Person responsible for payment of account:

Dental Insurance Information

Primary Coverage

Policy Holder:
Relationship to Patient:
Policy Holder's Date of Birth:
SSN:
Insurance Company:
Insurance Company Phone:
Employer:
Group or Policy Number:
Member ID Number:

Secondary Coverage

Policy Holder:
Relationship to Patient:
Policy Holder's Date of Birth:
SSN:
Insurance Company:
Insurance Company Phone:
Employer:
Group or Policy Number:
Member ID Number:
Patient Name:

Dental History

Has your child ever been to the dentist?

If yes, please describe:

Name of previous dentist:
Phone Number:
Date of first visit:
Date of last visit:
Reason for last visit:
Were x-rays taken of the teeth or jaw?
If yes, date of most recent dental x-rays:
Has your child ever had a difficult dental appointment?
If yes, describe:

Does your child have a history of any of the following? For each YES response, please describe:

Mouth sores or fever blisters
If yes, describe:
Bleeding gums
If yes, describe:
Cavities/decayed teeth
If yes, describe:
Toothache
If yes, describe:
Injury to teeth, mouth or jaws
If yes, describe:
Clinching or grinding his/her teeth
If yes, describe:
Jaw joint problems (popping, etc.)
If yes, describe:
Excessive gagging
If yes, describe:
Sucking habit after one year of age
If yes, which:
For how long?
At what age did your child stop bottle or breast feeding?

How would you describe:

Your child's oral health?
Your oral health?
Oral health of your other children
How often does your child brush his/her teeth? times per
Does someone help your child brush?
How often does your child floss his/her teeth? times per
Does someone help your child floss?
What toothpaste does your child use?
What type of water does your child drink at home?
Please check all the sources of fluoride your child receives:

Does your child go to bed with a bottle or sippy cup?
Is your child on a special or restricted diet?
Is your child a 'picky eater'?
Do you have any concerns regarding your child's weight?

How frequently does your child have the following?

Candy or other sweets
Chewing gum
Snacks between meals
Soft drinks *
* Such as juice, sodas, carbonated beverages, sweetened beverages, sports drinks or energy drinks
Please note any other significant dietary habits:
Has your child ever had a local anesthetic?
If yes, were there any adverse reactions?
Has your child ever been sedated for dental treatment?
If yes, list reason for sedation and date:
Has your child had any orthodontic treatment?
If yes, list name of orthodontist:
City:
Is there anything else we should know before treating your child?
If yes, please describe:
Patient Name:

MEDICAL HISTORY

Child's Physician/Pediatrician:
Phone Number:
Mailing address:
City:
State:
Zip code:
Is your child in good health?
Date of last physical exam:
If no, please explain:
Are your child's immunizations current?
If no, list reason:
Is your child currently taking any prescription medications?
If yes, please give name, reason & date started:
Is your child currently taking any over the counter medications?
If yes, please give name, reason & date started:
Is your child currently taking any vitamins or dietary supplements?
If yes, please give name, reason & date started:
Has your child ever been hospitalized, had surgery and/or general anesthesia?
If yes, please list date and explain:
Has your child ever been treated in an emergency room?
If yes, please list date and explain:
Please indicate if your child has been diagnosed and/or treated for any of the following – if No, please select N for each:
Acid Reflux
ADHD
AIDS
Anemia
Arthritis Rheumatism
Artificial Heart Valves
Artificial Joints
Aperger's Syndrome
Asthma
Autism
Back Problems
Bleeding Abnormally
Extractions or Surgery
Blind
Blood disease
Cancer
Cerebral Palsy
Chemical dependency
Chemotherapy
Congenital Heart Lesions
Cortisone Treatments
Cough-persistent / bloody
Developmental Disorder
Diabetes
Down's Syndrome
Epilepsy
Fainting or Dizziness
Glaucoma
Headaches
Hearing Impaired
Heart Murmur
Heart Problems
Hepatitis
Type
Herpes
High Blood Pressure
HIV Positive
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorder
Mitral Valve Prolapse
Nervous Problems
Pervasive Developmental Disorder (PDD)
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Scoliosis
Seizures
Shortness of Breath
Sickle Cell Anemia
Sinus Trouble
Skin Trouble
Spinal Bifida
Stroke
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tourette's Syndrome
Tuberculosis
Tumor or growth on Head/Neck
Other
Has your child ever had any serious illness not listed above?
If yes, please explain:
Please list all known allergies for your child:
Food Allergies (List)
Other (List):
Does your child have any handicaps or disabilities?
If yes, please explain:
Has your child ever been evaluated by a specialist? If yes, please list:
Name:
Specialty:
Phone:
Name:
Specialty:
Phone:
Is there any other significant medical history pertaining to your child or his/her family that the dentist should be told?
If yes, describe:

I affirm that the information above is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child's health and it is my responsibility to inform the licensed professionals and staff of Dr. Jeannette M. Pope‐Ozimba’s Pediatric Dental Office of any changes in my child’s medical status.

Legal Guardian Signature:

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Legal Guardian Name (PRINT)
Date


PEDIATRIC DENTISTRY CONSENT FOR DENTAL PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

  1. State Law requires us to obtain your consent to your child’s contemplated dental treatment or oral surgery. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain it. I hereby authorize and direct Dr. Pope- Ozimba assisted by other dental and/or dental auxiliaries of her choice, to perform upon my child (or legal word for whom I am empowered to consent) the following dental treatment or oral surgery procedure(s).
  2. In general terms the dental treatment or procedures will include:
    1. Radiograph (x‐rays) of the teeth and jaws.
    2. Cleaning of the teeth and the application of topical fluoride.
    3. Application of plastic “sealants” to the grooves of the teeth.
    4. Use of local anesthesia to numb the teeth and tissues.
    5. Treatment of diseased or injured teeth with dental restorations (fillings).
    6. Removal (extraction) of one or more teeth.
    7. Treatment of diseased or injured oral tissues (hard and / or soft).
    8. Treatment of malposed (crooked) teeth and/or oral development or growth abnormalities.
    9. Use of sedative drugs to control apprehension and/or disruptive behavior.
    10. Use of General Anesthesia to accomplish the necessary treatment.

The nature and purpose of the treatment and procedures have been explained tome in general terms by Dr. Pope‐Ozimba and/or assistant. Alternates purpose of the treatment and procedures have been explained to me, as have their advantages and disadvantages, the risks, consequences and probable effectiveness of each, as well as the prognosis if no treatment is provided. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore there can be no guarantee as expressed or implied either as to the rest of the treatment or as to cure. I further authorize the doctor to perform other dental services that in her judgment are advisable for my child or legalward, with the exception of (if none so State).


  1. I also authorize Dr. Pope‐ Ozimba to use photographs, radiographs, and other diagnostic material and treatment records for the purpose of teaching, research, and scientific publications.
  2. Although their occurrence is not frequent, some risks and complications are known to be associated with dental or oral surgery procedures. The most common complication associated with pediatric dental treatment includes nausea following the administration of topical fluoride and children biting and injuring the tongue or lip following administration of local anesthesia. Less common complications includes the risks of numbness, infection, swelling prolonged bleeding, discoloration, vomiting, allergic reactions, swallowing or aspiration of a crown form, and extracted tooth or gauze packing; injury to the tongue and/or lips, damage to and possible loss of existing teeth and/or restorations (fillings), injury to nerves near the treatment site and fracture of a tooth root which may require additional surgery for its removal. For children with heart disease, the risk of subacute bacterial endocarditic (heart infarction) following dental treatment exists, therefore antibiotics will be prescribed before and following treatment, to minimize risk. I further understand and accept that complications may require additional medical, dental, or surgical treatment and may require hospitalization.

I hereby state that I have read and understand this consent form, that I have been given an opportunity to ask questions I might have, and that all questions about the procedure or procedures have been answered in a satisfactory manner; and I understand further that I have the right to be provided with answers to questions which may arise during the course of my child’s treatment.

I further understand that I am free to withdraw my consent to treatment at any time, and that this consent will remain in effect until such time that I choose to terminate it.

Patient's Name:
Email:
Phone Number:
Signature of Parent/Guardian

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Relationship to Patient:
Date:
Time:

I certify that I explained the above procedures to the parent or legal guardian before requesting their signature

Signature of Dentist

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Date:

Behavior Management Informed Consent

To the parent / guardian of:

Child's Name:
Birth Date:

As a concerned dentist, I would like to discuss with you the methods of managing your child’s behavior during treatment. While children are usually cooperative and brave, sometimes they can be frightened by the equipment and the unknown experience. This is especially true for children younger that three years, but it also hold true to some older children. In order to treat you child safely, we may have to use these aids:

  • Mouth Rester, to help hold the child’s mouth open to provide the dentist with better access and prevents the child from biting down on a working drill. If a child falls asleep during the procedure, the Mouth Rester will enable the dentist to continue to work without waking the child.
  • Holding Assistant, helps secure the child, protecting and positioning him on the dental chair. In addition, the assistant may comfort, massage, and soothe the child. This person may be you, parent / guardian.
  • Papoose boards, Pedi‐Wraps and/or Pillow Case, these are protective restraining stabilizers for limiting your child’s movement to prevent injury to the child and the providers. Protective stabilization enables the dentist to provide the necessary dental treatment. This child is wrapped in these stabilizers and placed in a reclined dental chair.

Note: Before giving us permission to use these aids, please feel free to ask questions or express any concerns. Please rest assure that you child will receive optimal treatment with us. These behavioral management aids are only used when necessary. Thank You. 



Parent/Guardian:
Date:
Doctor:
Date:
Interpreter / Witness:
Date:

Patient Behavior Management

This listed pediatric dentistry behavior management technique has been explained to me by Dr. Jeannette Pope-Ozimba. Alternate techniques for treatment, if any has also been explained to me, as have the advantages and disadvantages of each.

I hereby authorized and direct Dr. Pope-Ozimba assisted by other dentist and/or dental auxiliaries of her choice, to utilize the behavior management techniques listed on the reverse side of this form to assist on the provision of the necessary dental treatment as previously explained to me by Dr. Pope-Ozimba for my child (or legal ward) for whom I am empowered to consent with the exception of (in none, so state):


I also understand that there may be a $66.00 fee per 15 minutes during treatment for additional time. Insurance does not cover this fee. Payment will be due at the time of services. No exceptions!!!!!!!!!!

I hereby acknowledge that 1 have read and understand this consent form. I have been given the opportunity to ask questions that I might have, and all questions about the behavior techniques described have been answered in a satisfactory manner, and I further understand that I have the right to be provided with the answers to questions which may arise during the course of my child's treatment.

I further understand that I am free to withdraw my consent to treatment at any time and this consent shall remain in effect until I choose to terminate it.

Date
Time
File number
Patient's Name
Signature of Parent / Guardian

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Relationship to Patient

I certify that I explained the above procedure and techniques to the parent or legal guardian before requesting their signature.

Signature of Dentist

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Date

Office Policies

Thank you for choosing us as your child’s pediatric dentist. We are committed to the successful treatment of your child’s dental needs. Prior to any treatment being rendered, we require that you acknowledge in writing your receipt of this document and your understanding and agreement with the below policies.

Appointment Policy:

  1. We require at least 24 hours notification for appointment rescheduling or cancellation. This policy allows us to offer the appointment time to another child.
  2. Two (2) cancelled appointments with less than 24 hours notice or two (2) missed appointments will prevent further scheduling by our office
  3. We require verbal confirmation or electronic confirmation via text or email to hold the patient's appointment.
  4. Our office is very busy. We may not be able to see a patient who arrives 15 minutes or more late, and should the patient not be treated on the date of their appointment, it will be counted as a missed appointment. If a patient arrives more than 15 minutes late, the legal guardian has the following options:
    • Option 1: Reschedule the appointment.
    • Option 2: Wait to be filled in during an opening on the same day. *There are no guarantees on this option.*
  5. Scheduling family members together is a courtesy we extend to our patients. However, patients from the same family who have missed a family appointment or cancelled a family appointment with less than 24 hours notice will not be allowed to schedule appointments together again.
  6. A legal guardian, or an individual previously authorized by the legal guardian in writing, must accompany the patient to each dental visit and remain at our office throughout the entire appointment.
  7. We understand emergencies happen, especially with children. We are happy to see our patients on an emergency basis, but we do require an appointment for an emergency. Please call us before coming to the office and we will fill the patient in as soon as possible. However, if the patient does not show for an emergency appointment, he/she will not be rescheduled as an emergency. The patient will be rescheduled at our first available appointment.
  8. If the dentist(s) recommends the patient undergo outpatient dental surgery but the patient’s legal guardian chooses to forgo the recommended surgery the patient will be dismissed from the practice. We will see the patient on an emergency basis only for one month from the date of the surgery approval release

Financial Policy:

Our staff is happy to assist you with your insurance questions. As a courtesy, we will file the patient’s insurance claim. Please understand that we do not have a contract with the insurance company, only the insured does. It is therefore the insured’s responsibility to correct any problem of payment with the insurance company. We are not responsible for what benefits are or are not paid on a claim. We can only assist you in estimating your portion of the cost of treatment. We are not responsible for any errors in filing your claim.

If a patient does not have dental insurance or is not eligible for dental insurance, then payment in full is required on the day of service. If a patient is retro-activated with their insurance, then our office will reimburse the insured once our office has been paid by the insurance company.

When patients are scheduled for operative appointments (i.e. sealants, fillings, nitrous oxide, etc.) we will estimate the patient’s financial portion and require the estimated amount to be paid on the day of service. We accept cash, check, or credit card (Visa or MasterCard). There will be a $35 fee if your check is returned.

Medical Photography Release/Approval:

Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office is dedicated to the use of the most advanced technologies available in giving and documenting your child’s medical and dental care. To this end, we have invested in electronic medical records. This means that all items traditionally maintained in a paper format will be obtained, stored, and cataloged digitally. This record will also include digital photographs of your child(ren) for identification by our licensed professionals and staff. Any lesions, procedures, or other items which may be documented visually will also be stored and reproduced in this manner.

I hereby authorize the licensed professionals and staff of Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office to obtain and reproduce photographs of my child(ren)’s likeness(es) for purposes of medical records. I also approve the use and reproduction of clinical photos for referral, coding, charting, marketing, advertising, and educational purposes.

By executing below, I acknowledge I have read and understand the Office Policies for Dr. Jeannette M. Pope‐Ozimba's Pediatric Dental Office and will comply with same.

Patient Name (PRINT)
Date of Birth:
Date:
Legal Guardian Name (PRINT):
Legal Guardian Signature

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CONSENT FOR TREATMENT

I am the (parent or guardian) of (name of child) who is a minor child and I authorize examination and treatment as necessary by or under the supervision of Dr. Pope‐Ozimba. This includes exposure of radiographs as necessary, use of local anesthetic, reasonable restraints as needed, and use of appropriate medicaments and material for such treatment.

I give you office consent to discuss treatment concerning the above mentioned minor child to the following individual(s):

Name:
Name:
Name:

I understand that the above person(s) can not sign any consent forms pertaining to treatment for the above mentioned minor child.

I READ AND UNDERSTAND THE ABOVE INFORMATION AND THE INFORMATION GIVEN TO ME VERBALLY. BY MY SIGNATURE I CONSENT TO THE TREATMENT DESCRIBED IN THIS CONSENT FORM.

Parent Signature

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Date:
Witness

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Date:

Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgement* 

I, , have received a copy of this office’s Notice of Privacy Practices.

Signature

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Date

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: