Child's Health History Form

For patients under the age of 18 years old

PATIENT INFORMATION

Child's Legal Name:

First Name

Middle Initial

Last Name

Preferred Name

Social Security #

Date of Birth

Birth Sex

MaleFemaleDecline to Answer

Gender Identity

Male

Female

Transgender Man/transman

Transgender Woman/transwoman

Genderqueer/gender nonconforming neither exclusively male nor female

Additional gender category, please specify:

Decline to Answer

Preferred Pronouns

He/Him

She/Her

They/Them

Other, please specify:

Race/Ethnicity

Name/age and relationship of others living in the household

List any sports of extracurricular activities

How did you hear about us/who referred you to us?

Home Address

City

State

Zip

Primary Phone Number

Secondary Phone Number

Parent's/Guradian's Name

Relationship to Patient

Email Address

Is parent's address the same as child's address? If no, please list below

YesNo

Parent's Address

City

State

Zip

Parent's Date of Birth

Employer

Occupation

MEDICAL INFORMATION

Primary Physician

Address/Phone

Medical Specialists

Address/Phone

Is your child being treated by a physician at this time?

YesNo

Reason

Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements?

YesNo

List Name(s)

Dose, frequency, & date started

Has your child ever been hospitalized, had surgery, or a significant injury, or been treated in an emergency department?

YesNo

List date & describe

ADDITIONAL PARENT/GUARDIAN INFORMATION

Parent's/Guradian's Name

Relationship to Patient

Email Address

Home Phone

Cell Phone

Work Phone

Is parent's address the same as child's address? If no, please list below

YesNo

Parent's Address

City

State

Zip

Parent's Date of Birth

Employer and Occupation

I acknowledge that the parent(s)/guardian(s) listed on this form can legally make treatment decisions for the patient.

Parent's/Guradian's Name

Parent's/Guradian's Signature

In the event that neither listed parent/guardian can bring the patient to their appointment, please complete the following section.

I,(Name of Parent or Legal Guardian), give permission to the following individual(s) listed below to accompany my child,(child's name) to their dental visit at Surfside Smile Co. Pediatric Dentistry & Orthodontics. With this I realize the individual(s) listed below will have the authority to make all necessary treatment decisions while my child is present at their dental visit. I will be available to be reached at(phone number) if necessary during their dental visit in case of emergency.

All individuals listed below must be 18 years of age or older and will need to present a photo ID at check-in prior to your child being seen.

Full name of individual to accompany child

Relationship to child

Full name of individual to accompany child

Relationship to child

Full name of individual to accompany child

Relationship to child

Parent's/Guradian's Signature

Printed Name

Date

EMERGENCY CONTACT INFORMATION

First and Last Name

Relationship to Patient

Phone Number

RELEASE OF INFORMATION

Please list individuals that are OK to have appointment or medically related information released to concerning the patient. List up to 4 people.

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (if different from page 1)

City

State

Zip

Phone Number

E-mail

Social Security Number

Employer

Who will be responsible for bringing patient to appointments?

DENTAL INSURANCE

Primary policy holder's full name

Policy Holder Birthdate

Social Security Number

Relationship to patient

Address and phone (if not previously listed)

Employer

Address (street, city, zip)

Insurance Company

Group #

Policy #

Insurance Company Phone # (on back of card)

Does this policy have orthodontic benefits?YesNoDon't know

Secondary policy holder's full name

Policy Holder Birthdate

Social Security Number

Relationship to patient

Address and phone (if not previously listed)

Employer

Address (street, city, zip)

Insurance Company

Group #

Policy #

Insurance Company Phone # (on back of card)

Does this policy have orthodontic benefits?YesNoDon't know

MEDICAL INSURANCE

Policy holder's full name

Insurance Company

RELEASE AND WAIVER

I have read the above questions and understand them. I will not hold Surfside Smile Co. Pediatric Dentistry & Orthodontics, my dentist and/or orthodontist, or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my provider of any changes in my child's medical or dental health.

I authorize release of any information regarding my child's dental or orthodontic treatment to my dental and/or medical insurance company necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office and I understand that I am responsible for any amount not covered by insurance.

Signature of parent/guardian

Printed Name

Relationship to child

Date

PRIVACY CONSENT

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this Consent. You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such a revocation will not be effective to the extent that any action has beentaken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.

Signature of parent/guardian

Printed Name

Relationship to child

Date

Not offering consent

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify)

Child's Health History Form

For patients under the age of 18 years old

PATIENT INFORMATION

MEDICAL INFORMATION

Please mark YES if your child has a history of the following conditions. For each "YES", provide details in the box at the bottom of this list. Mark NO after each line if none of those conditions applies to your child.

ADDITIONAL PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

RELEASE OF INFORMATION

DENTAL HEALTH QUESTIONNAIRE

Please complete the following orthodontic supplemental section if you are registering your child as an ORTHODONTIC patient

ORTHODONTIC SUPPLEMENTAL FORM

Please complete the following supplemental section if your child is under THREE years old:

INFANT AND TODDLER SUPPLEMENTAL FORM

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

RELEASE AND WAIVER

PRIVACY CONSENT