Patient Information for a Minor Patient
For information requested that is not applicable, please leave blank.
Patient’s primary residence:
Head of Household (1st parent) – Personal Information
By providing your e-mail address you agree to receive (choose one or both):
Do you wish to receive text message appointment reminders?
Spouse (2nd parent) – Personal Information
By providing your e-mail address you agree to receive (choose one or both):
Do you wish to receive text message appointment reminders?
Primary Dental Insurance Information
Secondary Dental Insurance Information
Cancellation Policy

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.

Authorizations for Responsible Party Form

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.
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.
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.
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.
Medical & Dental History for a Minor Patient
Medical History (Please choose Yes or No for each)
3. Patient is in good health?
4. Patient has regular medical exams?
5. Patient is up to date with immunizations?
6. Patient is presently taking medications?
If yes, please list and give reason.
7. Patient has allergies (medications, food, latex/rubber)?
8. Has the patient been hospitalized, had an operation or had general anesthesia?
9. Has the patient had any complications from general anesthesia in the past?
Has the patient experienced, have or had any of the following? (Please choose Yes or No for each)
Arthritis, rheumatism
Artificial joints, implants, organs
Autism spectrum disorder
Blood disorder
Blurred vision
Bone pain
Canker or cold sores
Cerebral palsy
Chest pain, tightness, wheezing
Downs syndrome
Excessive thirst
Eye disease
Fainting spells
Family history of diabetes
Frequent urination
Frequent vomiting
Hearing problems, ear pain
Heart attack
Heart defects
Heart disease, murmurs
High blood pressure
Joint pain or stiffness
Kidney or bladder disease
Muscle pain, weakness
Persistent cough, runny nose
Recent significant weight loss
Rheumatic fever
Sensory disorders
Shortness of breath
Skin disease
Spina bifida
Stomach problems or ulcers
Thyroid disease
Tumors or cancer
Urinary tract infections
This information will not be released unless specifically authorized by patient.
Treatment for emotional, mental, physical delays
10. Does the patient have or has he/she had any other medical problems not listed on this form?
12. Is there an issue you would like to discuss with the dentist in private?
Dental Health History
13. Is this the patient’s first dental visit?
17. Does the patient respond well to his/her pediatrician or previous dentist?
Has the patient experienced any of the following? (Please choose Yes or No for each)
Injuries to the face, mouth, or teeth
Thumb, finger, or pacifier sucking?
Missing or extra permanent teeth?
Mouth breathing, snoring, enlarged tonsils?
Habits (cheek biting, tongue thrusting)
Speech problems?
Habit of going to bed with a bottle?
Jaw pain, clenching or grinding?
18. Does the patient use any fluoride supplements (rinses, vitamins)?
19. Has the patient ever been evaluated for or had orthodontic treatment?

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.