Patient Information Form

Cancellations without a 24 hours or 1 business day notice and failure to show for scheduled appointments will result in a $50.00 fee Per Patient.

We are committed to providing you and/or your child with the best possible care. Toward this goal, we would like to explain your financial and scheduling responsibilities with our practice.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice.

We accept the following forms of payment: Cash, Electronic check, Visa, MasterCard, American Express, Discover, Care Credit. (Note: if Social Security number is not provided, only cash and credit cards will be accepted).

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contact negotiated between you or your employer and the plan. We are happy to help our patients or parents and guardians of our patients with dental benefit plans to understand and maximize their coverage.

You are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this and you will be responsible for the difference.

It is the insured’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We make every effort to stay within the time allotted to care for our patients. This is not always possible due to variability inherently present when treating pediatric patients. We do not ‘overbook’ our schedule in anticipation of having any patients not able to make their scheduled time.

Many people are affected when a child misses an appointment: the child, someone else’s child who could have benefited from that appointment time, and the entire staff. We reserve the right to not reschedule any patient after three dental appointments missed without 48-hour notice. Thank you for your understanding.

Patient Privacy: Due to patient privacy concerns, audio and video recording is prohibited in this office. Any recording tape, data or broadcast becomes the property of Bryan Randolph, DDS, a Professional Dental Corporation.

Authorizations: I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I or my child may need and have consented to during diagnosis and treatment.

(initial)

I authorize the release of information necessary to process my dental benefit claims. I hereby authorize payment directly to this doctor otherwise payable to me.

Yes

(initial)

I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

(initial)

I hereby acknowledge that a copy of this practice’s Dental Materials Fact Sheet has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.

(initial)

Signature of Responsible Party:

Date:

Patient Name:

Date of Birth:

Medical History (Please choose Yes or No for each)

1. Physician's Name:

2. Physician's Phone Number:

Child's Weight:

3. Patient is in good health?

Yes

If no, why?

4. Patient has regular medical exams?

Yes

5. Patient is up to date with immunizations?

Yes

6. Patient is presently taking medications?

Yes

If yes, please list and give reason.

Medication:

Reason:

Medication:

Reason:

Medication:

Reason:

Medication:

Reason:

7. Patient has allergies (medications, food, latex/rubber)?

Yes

If yes, what allergies?

8. Has the patient been hospitalized, had an operation or had general anesthesia?

Yes

If yes, why and when?

9. Has the patient had any complications from general anesthesia in the past?

Yes

If yes, please explain complications:

Has the patient experienced, have or had any of the following? (Please choose Yes or No for each)

Yes

Treatment for emotional, mental, physical delays

Yes

AIDS/HIV

Yes

Anxiety

Yes

Depression

Please explain any yes answers:

10. Does the patient have or has he/she had any other medical problems not listed on this form?

Yes

11. If yes, please explain:

12. Is there an issue you would like to discuss with the dentist in private?

Yes

13. Is this the patient’s first dental visit?

Yes

Reason for visit:

14. Date of last dental examination:

15. Name of patient’s previous dentist:

16. Date of last dental radiographs (X-rays):

17. Does the patient respond well to his/her pediatrician or previous dentist?

Yes

If no, please explain:

Yes

Injuries to the face, mouth, or teeth

Yes

Thumb, finger, or pacifier sucking?

Yes

Missing or extra permanent teeth?

Yes

Mouth breathing, snoring, enlarged tonsils?

Yes

Habits (cheek biting, tongue thrusting)

Yes

Speech problems?

Yes

Habit of going to bed with a bottle?

Yes

Jaw pain, clenching or grinding?

18. Does the patient use any fluoride supplements (rinses, vitamins)?

Yes

If yes, name of product:

19. Has the patient ever been evaluated for or had orthodontic treatment?

Yes

20. If considering orthodontic treatment, what would you most like it to accomplish for the patient?

If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement, during and after dental treatment. I authorize the dentist to contact the patient’s physician at any time for any reason. I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my child’s dentist of any change in my child’s health or medication. Further, I will not hold my child’s dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

I have read and reviewed my child’s Health History and confirm that it accurately states past and present conditions.