Fishers Pediatric Dentistry

  

Enter names of children to update health history for using this form.

Patient 1
Patient 2
Patient 3
Patient 4



 

Patient: 1 -   Click to expand/collapse section

GENERAL HEALTH SCREENING

 
 
,
CONDITIONS
 
 
 
ALLERGIES
 
MEDICATIONS
 
 
DENTAL CONCERNS
 
CONSENT FOR TODAY

Patient: 2 -   Click to expand/collapse section

GENERAL HEALTH SCREENING

 
 
,
CONDITIONS
 
 
 
ALLERGIES
 
MEDICATIONS
 
 
DENTAL CONCERNS
 
CONSENT FOR TODAY

Patient: 3 -   Click to expand/collapse section

GENERAL HEALTH SCREENING

 
 
,
CONDITIONS
 
 
 
ALLERGIES
 
MEDICATIONS
 
 
DENTAL CONCERNS
 
CONSENT FOR TODAY

Patient: 4 -   Click to expand/collapse section

GENERAL HEALTH SCREENING

 
 
,
CONDITIONS
 
 
 
ALLERGIES
 
MEDICATIONS
 
 
DENTAL CONCERNS
 
CONSENT FOR TODAY

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
Below is a list of ways 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 from our dental office.
 
 
 
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 during the period of such dental care to third party payers and/or other health practitioners.  In the event of my absence, the following individuals may bring my child/children to and from their appointments along with have access to medical and financial information.
 
 
 ,
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 understand 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. If necessary, unpaid accounts may be sent to a collection agency. 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.
 

Signature (* required)