Medical History Update

PATIENT INFORMATION & MEDICAL HISTORY UPDATE

All questions contained in this questionnaire are strictly confidential and will become part of the patient’s record.

A Medical History Update must be provided at every dental visit.

ACTUALIZACIÓN DEL HISTORIAL MÉDICO

Todas las preguntas de este cuestionario son estrictamente confidenciales y serán parte del historial del paciente.

El historial médico debe ser actualizado durante cada visita dental.

DO YOU HAVE ANY CHANGES TO INSURANCE?

Yes

GENERAL INFORMATION

Primary billing address:

Street

City

State

Zip

Phone number & email for communication:

Phone

Name of who is accompanying the children on the date of their appointment?

Relation to patients:

Biological

Adopted

Foster

Nanny

Other

Are any of the children a ward of the state?

Yes

If yes, case worker's contact number:

IDENTIFICATION OF ACCOMPANYING PARENT / GUARDIAN

For the safety of your child, we require a copy of the driver's license for the person accompanying your child to their appointment.

To save time when you arrive, upload a copy now.

Upload image of front of license.

Upload image of back of license.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

Below is a list of ways that our office may contact you. Please check all that apply. Checking a box will give permission to leave as thorough of a message as needed.

PHONE NUMBER

You will receive text message communications to the cell number provided related to appointment reminders, healthcare information and billing matters. Please note you may be charged message and data rates by my wireless carrier. Such messages may be generated by an automated messaging system, and you may opt-out of this service by replying STOP to any message.

In the event of your absence, the following individual(s) may bring your child/children to and from their appointments along with have access to medical and financial information.

Patient Authorization for Use and Disclosure of Protected Health Information: I authorize Fishers Pediatric Dentistry to release any information including diagnosis and the records regarding any treatment or examination rendered to my child/children during the period of such dental care to third party payers and/or other health practitioners.

1. First Name:

Last Name:

Relationship to patient:

Contact Number:

2. First Name:

Last Name:

Relationship to patient:

Contact Number:

I understand that I can request a copy of this office’s Notice of Privacy Practices: (initial)

OFFICE POLICIES / FINANCIAL AGREEMENT

I certify that the information I have given is correct to the best of my knowledge. It will be held in confidence, and it is my responsibility to inform this office of changes in the patient’s medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I authorize the release of all information necessary to secure benefits otherwise payable to me. I assign directly Fishers Pediatric Dentistry all insurance payments otherwise payable to me. I understand that I am responsible for the full balance of the account regardless of my dental benefits. I acknowledge that the office operates on a 15-day billing cycle and account balances are due and payable when the statement is issued and is past due if not paid by the date printed on the statement. Past due accounts will incur late charges between $10 and $25 and can be sent to a collection agency if unpaid. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the dentist or any member of the staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I affirm that my signature represents my agreement to all the above mentioned terms.

PARENT / GUARDIAN First & Last name :

Signature

Date: