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.

 
GENERAL INFORMATION
PATIENT INFORMATION & MEDICAL HISTORY UPDATE

Please list FIRST & LAST NAME of all children being seen for treatment.

Patient’s First & Last Name:
Date of Birth:
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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.


CONSENT FOR TODAY: Consent is given for Fishers Pediatric Dentistry to provide treatment to the patient(s) listed above.
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Patient
PATIENT COMMUNICATION & HIPAA NOTICE OF PRIVACY PRACTICES

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.

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

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.

APPOINTMENT POLICY & FINANCIAL AGREEMENT

When we schedule an appointment for your child, that time is reserved solely for your child. We do not double book, and we take pride in the fact that we make every effort to see your child at the time scheduled. If you are more than 10 minutes late , it may be necessary to reschedule your child's visit. In the event you need to cancel or reschedule, we kindly ask that you give us 48 hours notice.

Any appointment that is not confirmed within 24 hours of the appointment time will be cancelled so that we may offer that time to another child. A failed appointment may result in a $25 no show fee and / or dismissal from the practice.

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.