HEALTH HISTORY FORM
CHILD'S INFORMATION
CHILD'S NAME:
PREFERRED NAME:
GENDER:
MALE
FEMALE
OTHER:
BIRTHDAY:
WHO DOES YOUR CHILD LIVE WITH:
CHILD'S ADDRESS:
HOW DID YOU HEAR ABOUT OUR OFFICE?:
PARENT/LEGAL GUARDIAN INFORMATION
PARENT #1/GUARDIAN NAME:
RELATIONSHIP:
BIRTHDAY:
SSN:
ADDRESS:
EMAIL:
PHONE:
SECONDARY PHONE:
EMPLOYER:
OCCUPATION:
PARENT #2/GUARDIAN NAME:
RELATIONSHIP:
BIRTHDAY:
SSN:
ADDRESS:
EMAIL:
PHONE:
SECONDARY PHONE:
EMPLOYER:
OCCUPATION:
PERSON RESPONSIBLE FOR ACCOUNT & BILLING
NAME:
RELATIONSHIP TO CHILD:
PARENT 1 LISTED ABOVE
PARENT 2 LISTED ABOVE
MOTHER
FATHER
STEP MOTHER
STEP FATHER
GRANDPARENT
GUARDIAN
OTHER (EXPLAIN):
IF PARENT 1 OR 2 LISTED ABOVE, YOU CAN SKIP THE REMAINDER OF THIS BOX UNLESS BILLING ADDRESS IS DIFFERENT.
BILLING ADDRESS:
EMAIL:
PHONE:
SECONDARY PHONE:
CHILD'S SOCIAL HISTORY
NAME AND AGE OF ANY SIBLINGS:
DOES YOUR CHILD HAVE BEHAVIORAL OR LEARNING ISSUES:
YES
NO
IF YES DESCRIBE:
DESCRIBE YOUR CHILD:
ANXIOUS
FRIENDLY
STUBBORN
DEFIANT
MOODY
OUTGOING
SHY
TRUSTING
MELLOW
CURIOUS
COOPERATIVE
HYPER
DOES NOT APPLY
CHILD'S INTERESTS:
ANYTHING ELSE YOU WANT TO SHARE ABOUT YOUR CHILD:
MEDICAL HISTORY
HAS YOUR CHILD HAD ANY OF THE FOLLOWING CONDITIONS:
COMPLICATIONS BEFORE OR AT BIRTH OR PREMATURITY
PROBLEMS WITH PHYSICAL GROWTH OR DEVELOPMENT
CONGENITAL HEART DEFECTS/DISEASE
BLOOD/BLEEDING DISORDER
CANCER
CHEMO THERAPY, RADIATION THERAPY, BONE MARROW OR ORGAN TRANSPLANT
BLOOD TRANSFUSIONS OR RECEIVING BLOOD PRODUCTS
HORMONE PROBLEMS
KIDNEY PROBLEMS
LIVER PROBLEMS
ASTHMA OR BREATHING PROBLEMS
DIABETES, HYPERGLYCEMIA OR HYPOGLYCEMIA
SEIZURES OR EPILEPSY
HYDROCEPHALUS
BONE OR JOINT PROBLEMS
AUTISM SPECTRUM DISORDER
DEVELOPMENTAL DISORDERS, LEARNING PROBLEMS, INTELLECTUAL DISABILITY
IMPAIRED VISION, HEARING OR SPEECH
BEHAVIORAL, EMOTIONAL OR PSYCHIATRIC PROBLEMS
HIV/AIDS
RHEUMATIC OR SCARLET FEVER
ACID REFLUX
OTHER MEDICAL PROBLEMS (IF YES, LIST BELOW)
NONE OF THE ABOVE
PLEASE LIST ANY DETAILS FOR CHECKED ITEMS OR NAME ANY MEDICAL CONDITIONS NOT CHECKED:
CHILD'S PHYSICIAN:
PHYSICIAN PHONE:
DOES YOUR CHILD SEE ANY OTHER MEDICAL SPECIALIST FOR OTHER CONDITIONS? I.E. CARDIOLOGIST, PULMONOLOGIST, ETC.
NO
IF YES:
TYPE OF SPECIALIST:
NAME OF SPECIALIST:
PHONE:
IS YOUR CHILD UP TO DATE ON VACCINATIONS?
YES
NO
ANY HOSPITALIZATIONS OR SURGERIES (IF YES, DESCRIBE AND PUT DATE BELOW):
NO
LIST ALL MEDICATIONS YOUR CHILD IS TAKING INCLUDING FREQUENCY AND DOSAGE:
NO
LIST ANY FOOD OR MEDICATION ALLERGIES:
NO
HAVE YOU EVER BEEN TOLD BY A PHYSICIAN THAT YOUR CHILD NEEDS AN ANTIBIOTIC PRIOR TO DENTAL CLEANINGS OR TREATMENT?
YES
NO
DENTAL HISTORY
REASON FOR TODAYS VISIT:
IS THIS YOUR CHILD'S FIRST DENTAL VISIT?
YES
NO
PREVIOUS DENTIST'S NAME:
HAS YOUR CHILD HAD ANY RECENT DENTAL PAIN?
YES
NO
IF YES, EXPLAIN:
DO YOU HAVE FLUORIDATED WATER?
YES
NO
IS YOUR CHILD ON A RESTRICTED OR SPECIAL DIET?
YES
NO
DOES YOUR CHILD DRINK JUICE, SPORTS DRINKS OR SODA ?
YES
NO
SOMETIMES
DOES YOUR CHILD EAT SWEETS, GUMMIE/FRUIT SNACKS OR CRACKERS?
YES
NO
PLEASE NOTE ANY OTHER SIGNIFICANT DIETARY HABITS:
HOW OFTEN DOES YOUR CHILD BRUSH?
DAILY
WEEKLY
RARELY
FLOSS?
DAILY
WEEKLY
RARELY
DOES SOMEONE HELP YOUR CHILD BRUSH/FLOSS?
YES
NO
DOES YOUR CHILD USE A FLUORIDE TOOTHPASTE?
YES
NO
UNKNOWN
HAS YOUR CHILD HAD ANY NEGATIVE DENTAL EXPERIENCE?
YES
NO
IF YES, EXPLAIN:
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING HABITS?
PACIFIER
THUMB/FINGER SUCKING
MOUTHBREATHING/SNORING
GRINDING/CLENCHING TEETH
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING?
DENTAL DECAY
BLEEDING GUMS
BAD BREATH
HISTORY OF TOOTH/JAW INJURIES
JAW JOINT PROBLEMS
DENTAL INSURANCE INFORMATION
NO INSURANCE
OTHER PAYMENT SOURCES
PRIMARY INSURANCE
INSURANCE COMPANY:
INSURANCE COMPANY PHONE:
MEMBER ID:
GROUP ID:
POLICY HOLDER NAME:
POLICY HOLDER SSN:
POLICY HOLDER BIRTHDATE:
POLICY HOLDER EMPLOYER:
Front of insurance card
Back of insurance card
SECONDARY INSURANCE
INSURANCE COMPANY:
INSURANCE COMPANY PHONE:
MEMBER ID:
GROUP ID:
POLICY HOLDER NAME:
POLICY HOLDER SSN:
POLICY HOLDER BIRTHDATE:
POLICY HOLDER EMPLOYER:
Front of insurance card
Back of insurance card
NON-PARENTAL CONSENT
I HEREBY GIVE MY WRITTEN PERMISSION FOR MY CHILD TO BE TREATED BY LITTLE SMILES. IN ADDITION, I GIVE MY PERMISSION FOR THE FOLLOWING ACCOMPANYING ADULT(S) TO DO THE THINGS CHECKED IN THE BOXES BELOW.
FIRST AND LAST NAME OF ADULT(S) AND THEIR RELATIONSHIP TO THE PATIENT:
GRANTING THEM PERMISSION TO (CHECK ALL THAT APPLY):
SCHEDULE ANY FURTHER NECESSARY DENTAL APPOINTMENTS
DISCUSS RECOMMENDED TREATMENT, INCLUDING BUT NOT LIMITED TO: RADIOGRAPHS, HYGIENE EVALUTATIONS, RESTORATIVE AND APPLICABLE APPLIANCE THERAPIES FOR MY CHILD
DISCUSS FINANCIAL INFORMATION OF MY CHILD'S ACCOUNT
I FURTHER UNDERSTAND THAT ANY FINANCIAL DECISIONS REGARDING MY CHILD'S ACCOUNT WILL REQUIRE MY WRITTEN AUTHORIZATION PRIOR TO DENTAL TREATMENT AND ANY AND ALL CHARGES TO THE ACCOUNT WILL BE MY PERSONAL RESPONSIBILITY TO BE PAID IN ACCORDANCE WITH LITTLE SMILES FINANCIAL PROTOCOL.
OFFICE GUIDELINES
YOUR APPOINTMENT:
PLEASE MAKE EVERY EFFORT TO ARRIVE ON TIME TO YOUR APPOINTMENT. WE WILL CONTACT YOU BEFORE YOUR APPOINTMENT TO CONFIRM. VOICEMAIL, TEXT AND EMAIL ARE AVAILABLE IF YOU ARE UNAVAILABLE AT THE TIME OF OUR CALL. WE SPECIFICALLY RESERVE THE REQUIRED AMOUNT OF TIME FOR YOUR CHILD'S PLANNED TREATMENT. IF YOU ARRIVE MORE THAN 15 MINUTES LATE, YOUR CHILD'S APPOINTMENT MAY NEED TO BE RESCHEDULED OR ALL PLANNED TREATMENT MAY NOT BE ABLE TO BE COMPLETED AT THAT VISIT.
CANCELLATION/RESCHEDULE:
SHOULD YOU NEED TO RESCHEDULE YOUR CHILD'S APPOINTMENT; WE REQUEST A 48- HOUR NOTICE WITH A MINIMUM OF 24-HOUR ADVANCE NOTICE. WE UNDERSTAND THAT CANCELLATIONS ON SHORT NOTICE DUE TO EMERGENCIES AND LAST-MINUTE DEVELOPMENTS MAY ARISE AND CAN HAPPEN TO ALL OF US. HOWEVER, LACK OF REASONABLE, ADVANCED NOTICE RESULTS IN LOST OPPORTUNITES TO SERVE OTHERS.
FAILED APPOINTMENT POLICY:
IF THE PATIENT ARRIVES MORE THAN 15 MINUTES LATE, FAILS OR CANCELS SCHEDULED APPOINTMENTS WITHOUT 48 HOURS ADVANCED NOTICE, WE RESERVE THE RIGHT TO CHARGE A $25 FEE.
STATEMENTS:
WE SEND MONTHLY STATEMENTS ON ALL OPEN ACCOUNT BALANCES, SO THAT YOU ARE AWARE OF WHAT PAYMENTS HAVE BEEN MADE TO YOUR ACCOUNT. UNLESS SPECIFIC ARRANGEMENTS HAVE BEEN MADE WITH OUR BUSINESS ASSISTANTS ALL ACCOUNTS OVER 90 DAYS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. THERE IS A $50 CHARGE TO ALL ACCOUNTS THAT ARE SENT TO COLLECTIONS.
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED:
WE WILL MAKE OUR BEST EFFORT TO ACCURATELY ESTIMATE THE AMOUNT OF PAYMENT DUE AT YOUR RECALL APPOINTMENT BASED ON YOUR INSURANCE POLICY'S DEDUCTIBLE, CO-PAY, CO-INSURANCE AND OUT OF POCKET MAXIMUM OF COVERED SERVICES. THIS PAYMENT IS DUE THE DAY SERVICES ARE PROVIDED. IN SOME CASES, INSURANCE COMPANIES USE OUTDATED FEE SCHEDULES OR REQUIRE A LARGER CO-PAY; THEREFORE, IT IS NOT POSSIBLE TO GIVE YOU A COMPLETELY ACCURATE ESTIMATE. IT IS POSSIBLE THAT YOU WILL OWE MORE ON YOUR CHILD'S ACCOUNT OR RECEIVE A CREDIT TO THEIR ACCOUNT, WHICH IS DETERMINED AFTER THE INSURANCE CLAIM IS RECEIVED BY OUR OFFICE.
WE ARE HAPPY TO FILE YOUR INSURANCE AS A COURTESY TO YOU:
KEEP IN MIND YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE HAVE NO SAY IN THE SELECTION OF YOUR INSURANCE COMPANY, NO CONTROL OVER THE TERMS OF YOUR CONTRACT AND NO DETERMINATION OF YOUR INSURANCE BENEFITS. YOU ARE RESPONSIBLE FOR THE FULL BALANCE INCLUDING ANY AMOUNT THAT IS NOT COVERED BY YOUR INSURANCE COMPANY. IF THE INSURANCE COMPANY DOES NOT PROCESS THE CLAIM WITHIN 45 DAYS OF SUBMISSION, YOU WILL BE RESPONSIBLE FOR THE BALANCE. IF YOU WOULD LIKE US TO FILE YOUR INSURANCE CLAIM FOR YOU PLEASE PROVIDE THE OFFICE WITH A COPY OF YOUR CURRENT INSURANCE CARD.
I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM AGREEING TO ALL GUIDELINES STATED.
SIGN
NAME
DATE