The Exchange Dental Group

39 Broadway Suite 2115, New York N.Y. 10006 – (212)422-9229- theexchangedentalgroup.com

Welcome

We would like to welcome your child to our office. Our goal is to make every child's visit pleasent and educational. Our practice is based on preventive care. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime!

Tell Us About Your Child

Date:
Child's Name
Child's Birthdate
Child's Age
Nick Name
School
Grade
Hobbies
Child's Home #
SS #
Child's Home Address
Phone
Email

General Information

Who is accompanying the child today?

Name
Relation
Do you have legal custody of this child?
Whom may we thank for referring you
Other Siblings
Previous / Present Dentist
Last Visit
Dentist's Phone

Relative or Friend not living with you

Name
Phone
Address

Parents Information

Who is responsible for account?
Parents Marital Status
Name
BirthDate
Address Home
SS#
DL#
Wk#
Ext
Cell / Other
Email
Employer
Employer's Address
City
State
Zip

If you have Dental Insurance Coverage for the Child, please fill out below:

Insurance Co Name
Insurance Address
City
State
Zip
Insurance Phone
Group#(Plan, Local or Policy#)
Name
BirthDate
Address Home
SS#
DL#
Wk#
Ext
Cell / Other
Email
Employer
Employer's Address
City
State
Zip

If you have Dental Insurance Coverage for the Child, please fill out below:

Insurance Co Name
Insurance Address
City
State
Zip
Insurance Phone
Group#(Plan, Local or Policy#)

I certify that my child is covered by Insurance Co. and I assign all insurance benefits otherwise payable to me.

I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submission, whether manual or electronic.

Signature of Insured:

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Date:

Dental & Medical History

Why did you bring the child to the dentist today?
Has the child ever taken any diet pill such as Phen-Fen
(Also known as Redux or Pondimin) if so, when?
Is the child currently in pain?
Does the child require antibiotics before dental treatment
Has the child ever had a serious/difficult problem associated with previous dental work?
Is the child water flouridated?
Is the child taking water fluoridated supplements?
Has the child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)?
Does the child brush his/her teeth daily?
Floss his/her teeth daily?
Child's Physician
Phone
Date of Last Visit
Is the child currently under the care of any physician?
Please describe the child's current physical health:
Please list all prescription/over the counter or herbal supplement drugs that the child is currently taking:
Aside from the item listed, list all drugs/things that the child is allergic to:
Latex
Metals / Nickel
Plastic

Has the child experienced the following medical problems?

Abnormal Bleeding / Hemophilia
Heart Murmur
ADD / ADHD
Hepatitis
AIDS / HIV
HBP
Anemia
Hives
Any Hospital Stays / Operations?
LBP
Kidney / Liver Problems
Asthma
Artificial Bones / Joints / Valves
Lupus
Cancer
Measles
Mitral Valve Prolapse
Chicken Pox
Congenital Heart Defect
Mononucleosis
Convulsions
Prosthetics
Rheumatic Fever
Diabetes
Exposed to HIV, but Neg.
Scarlet Fever
Sickle Cell Disease / Traits
Skin Rash
Handicaps / Disabilities
Tuberculosis
Hearing Impairment
Epilepsy
Are the child's immunizations current?
Anything you like to discuss with doctor in private?
Please discuss any serious medical problem the child experiences/ed

Does/did the child experience any of the following?

Breast Feed
Chewing on Objects
Clenching / Grinding Teeth
Lip Sucking / Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb / Finger Sucking
Tongue / Cheek Biting
Tongue Thrust
Used Pacifier

Our office Is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by 0SHA, the CDC and the ADA.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest 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.

Signature of Parent/Guardian

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Date

OFFICE USE ONLY

I have verbally reviewed the medical / dental information above with the parent / guardian & patient name herein

Signature of Dentist

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Date
Dentist's Comments

Medical History Update

Has there been any changes in your child's health status since their last visit?
If Yes, please explain
Parent/Guardian Signature

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Date
Signature of Dentist

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Date
Has there been any changes in your child's health status since their last visit?
If Yes, please explain
Parent/Guardian Signature

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Date
Signature of Dentist

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Date

Financial Policy

The Exchange Dental Group strives to be punctual, therefore we ask that our patients keep their appointments and also arrive on time. If a patient must cancel an appointment, we require at least 24 hours notice, with the exception of Sunday appointments which must be cancelled by Friday 12pm the latest. There will be a $100 charge for EACH appointment missed or not cancelled 24 hours prior to the scheduled time, or by Friday 12pm respectively.

The Exchange Dental Group will make every effort possible to assist our patients with their insurance, however please keep in mind that dental insurance is a contract between the insurance company and the patient, not the dental provider. It is up to the patient to fully understand his/her benefits to ensure the appropriate disbursement of benefits under the terms of each individual plan.

It is the patient's responsibility to notify The Exchange Dental Group should there be any change in the insurance plan. It is also the patient's responsibility to notify us of any dental procedures that have been done in other dental offices that may reduce the insurance benefits available for the year.

As a courtesy to our patients, The Exchange Dental Group provides a treatment plan of which includes an estimate of the recommended treatment, the expected coverage from the dental coverage as well as the patient's copayment respectively. Benefits quoted to you are only an estimate provided by the insurance company and not a guarantee of payment or eligibility at the time the services are performed. The Exchange Dental Group will submit claims and accept the assignment of benefits from the insurance company on behalf of the patient provided the patient pays their co-payment for each visit, due at the time of treatment, unless prior arrangements have been made, as we offer various financial programs to assist our patients with affordable monthly payments.

In the event that the claim is not paid by the insurance company within 30 days, the balance becomes the patient's responsibility and is due immediately. Any balances that remain unpaid after 90 days will be turned over to collections.

* Please note that a $25 returned check fee will be added to the balance for all returned checks.

A misunderstanding can be an obstacle in establishing a successful relationship. If at any time you have a question regarding treatment, fee or service, please discuss it with us promptly and openly.

I, the undersigned, have read and understood the above and I consent to all the terms and conditions set forth in this agreement.

Signature of Dentist

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Date