MEDICAL HISTORY CHILD'S PHYSICIAN'S NAME ADDRESS PHONE DATE LAST SAW PHYSICIAN

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1 Barbara A. Moyer, D.D.S., M.S. *THESE QUESTIONS ARE OF GREAT VALUE IN AIDING US TO A BETTER UNDERSTANDING OF YOUR CHILD CHILD'S NAME NAME CHILD PREFERS AGE DATE OF BIRTH SEX: M F TO BE CALLED ATTENDS SCHOOL AT GRADE SPORTS OR OTHER HOBBIES MUSICAL INSTRUMENTS PLAYED NO. OF SIBLINGS AND THEIR AGES OTHER FAMILY MEMBERS TREATED FOR ORTHO HERE WHAT IS YOUR PRIMARY CONCERN? WHY ARE YOU HERE? WHO REFERRED YOU TO OUR OFFICE? (WE WISH TO THANK THEM) MEDICAL HISTORY CHILD'S PHYSICIAN'S NAME ADDRESS PHONE DATE LAST SAW PHYSICIAN MONTH/YEAR REASON BIRTH FATHER'S HEIGHT ft. in. BIRTH MOTHER'S HEIGHT ft. in. PATIENT'S BIRTH WEIGHT lbs. oz. PATIENT'S PRESENT WEIGHT lbs. HEIGHT ft. in. NOW OR IN THE PAST, HAS YOUR CHILD HAD: BIRTH DEFECTS OR HEREDITARY PROBLEMS? YES NO BONE FRACTURES, OR ANY MAJOR ACCIDENTS? YES NO RHEUMATOID OR ARTHRITIC CONDITIONS? YES NO ENDOCRINE OR THYROID PROBLEMS? YES NO KIDNEY PROBLEMS? YES NO DIABETES? YES NO CANCER, TUMOR, RADIATION TREATMENT OR CHEMOTHERAPY? YES NO STOMACH OR OTHER G.I. PROBLEMS? YES NO POLIO, MONONUCLEOSIS, TUBERCULOSIS OR PNEUMONIA? YES NO PROBLEMS OF THE IMMUNE SYSTEM? YES NO AIDS OR HIV POSITIVE? YES NO HEPATITIS, JAUNDICE OR LIVER PROBLEM? YES NO VISION, HEARING, DIFFICULTIES? YES NO LOSS OF WEIGHT RECENTLY, POOR APPETITE? YES NO HISTORY OF EATING DISORDER (ANOREXIA OR BULIMIA)? YES NO BLEEDING DISORDER? YES NO HIGH OR LOW BLOOD PRESSURE? YES NO TIRES EASILY? YES NO CHEST PAIN, SHORTNESS OF BREATH OR SWELLING ANKLES? YES NO CARDIOVASCULAR PROBLEM (CONGENITAL HEART DEFECT, HEART MURMUR, RHEUMATIC FEVER) YES NO HEART SURGERY? EVER BEEN TOLD OF NEED FOR SBE PRE-MED? YES NO SKIN DISORDER? YES NO FREQUENT HEADACHES, COLDS, OR SORE THROATS? YES NO LARGE TONSILS OR ADENOIDS? HAVE THEY BEEN REMOVED? YES NO ADD, ADHD, OTHER LEARNING DISABILITIES? YES NO HAY FEVER, ASTHMA, SINUS TROUBLE, OR HIVES? YES NO ALLERGIES OR REACTIONS TO ANY OF THE FOLLOWING: LOCAL ANESTHETICS (NOVOCAIN OR LIDOCAINE) YES NO ASPIRIN YES NO IBUPROFEN (MOTRIN, ADVIL) YES NO PAGE 1 of 3

2 PENICILLIN OR OTHER ANTIBIOTICS YES NO CODEINE OR OTHER NARCOTICS YES NO METALS (JEWELRY, CLOTHING SNAPS) YES NO LATEX (GLOVES, BALLOONS) YES NO ANIMALS YES NO FOODS (SPECIFY) YES NO OTHER (SPECIFY) YES NO IS YOUR CHILD CURRENTLY TAKING ANY PRESCRIPTION OR NON-PRESCRIPTION MEDICATIONS? YES NO PLEASE LIST: MEDICATION TAKEN FOR MEDICATION TAKEN FOR MEDICATION TAKEN FOR DOES YOUR CHILD CURRENTLY HAVE OR EVER HAD A SUBSTANCE ABUSE PROBLEM? YES NO DOES YOUR CHILD CHEW OR SMOKE TOBACCO? YES NO OPERATIONS? DESCRIBE: YES NO HOSPITALIZED? FOR: YES NO ARE THERE ANY OTHER MEDICAL CONDITIONS THAT WE SHOULD BE AWARE OF? GIRLS ONLY HAS YOUR CHILD STARTED HER MONTHLY PERIODS? YES NO IF SO, APPROXIMATELY WHEN? IS YOUR CHILD PREGNANT? YES NO FAMILY MEDICAL/ DENTAL HISTORY IS THERE ANY FAMILY HISTORY OF THE FOLLOWING HEALTH PROBLEMS? IF SO, PLEASE EXPLAIN BLEEDING DISORDERS YES NO DIABETES YES NO ARTHRITIS YES NO METABOLIC DISTURBANCES YES NO SEVERE ALLERGIES YES NO UNUSUAL DENTAL PROBLEMS YES NO JAW SIZE IMBALANCE YES NO MISSING/ IMPACTED TEETH YES NO DID EITHER PARENT HAVE/ NEED ORTHODONTIC TREATMENT? YES NO ANY OTHER FAMILY MEDICAL CONDITIONS THAT WE SHOULD KNOW ABOUT? YES NO DENTAL HISTORY CHILD'S DENTIST ADDRESS DATE LAST VISIT DR. NICK MOYER REASON: OTHER: NOW OR IN THE PAST, HAS YOUR CHILD HAD: VERY EARLY OR VERY LATE ERUPTION OF TEETH? YES NO PRIMARY (BABY) TEETH REMOVED THAT WERE NOT LOOSE? YES NO SUPERNUMERARY (EXTRA) OR CONGENITALLY MISSING TEETH? YES NO PROBLEMS WITH EXCESSIVE CAVITIES? YES NO ROOT CANALS? YES NO PERIODONTAL "GUM PROBLEMS"? YES NO HAD PERIODONTAL (GUM) TREATMENT? YES NO THUMB, FINGER, OR SUCKING HABIT? UNTIL WHAT AGE? YES NO ABNORMAL SWALLOWING HABIT (TONGUE THRUSTING)? YES NO HISTORY OF SPEECH PROBLEMS? YES NO MOUTH BREATHING HABIT, SNORING OR DIFFICULTY IN BREATHING? YES NO TOOTH GRINDING, JAW CLENCHING, CLICKING OR LOCKING? YES NO ANY PAIN IN JAW OR RINGING IN THE EARS? YES NO DIFFICULTY ENCOUNTERED IN CHEWING OR JAW OPENING? YES NO SPACED, CROOKED OR PROTRUDING TEETH? YES NO AWARE OR CONCERNED ABOUT UNDER OR OVER DEVELOPED JAW? YES NO ANY RELATIVE WITH SIMILAR TOOTH OR JAW RELATIONSHIPS? YES NO WOULD YOUR CHILD OBJECT TO WEARING ORTHODONTIC APPLIANCES (BRACES) YES NO HAS YOUR CHILD EVER HAD A PRIOR ORTHODONTIC EXAMINATION OR TREATMENT? YES NO PAGE 2 of 3

3 HAS YOUR CHILD BEEN UNDER ANOTHER DENTIST'S CARE OTHER THAN FOR ROUTINE PREVENTATIVE CARE? YES NO SPECIALIST? YES NO OTHER? YES NO HAS YOUR CHILD EXPERIENCED ANY UNFAVORABLE REACTION FROM MEDICAL OR DENTAL CARE? YES NO IF SO, EXPLAIN: PREVENTATIVE DENTAL HISTORY HOW OFTEN DOES YOUR CHILD BRUSH? IS TOOTH BRUSHING SUPERVISED? BY WHOM? YES NO IS DENTAL FLOSS USED? DOES YOUR CHILD RECEIVE: (CHECK) NONE YES NO FLUORIDE IN VITAMINS FLUORIDE IN TABLETS/DROPS FLUORIDATED WATER PATIENT PROFILE DOES PATIENT FOLLOW DIRECTIONS WELL ALWAYS USUALLY SOMETIMES USUALLY NOT DOES PATIENT BRUSH HIS/HER TEETH CONSCIENTIOUSLY? YES NO DOES PATIENT HAVE LEARNING DISABILITIES OR NEED EXTRA HELP WITH INSTRUCTIONS? YES NO IS PATIENT SENSITIVE OR SELF-CONSCIOUS ABOUT TEETH? YES NO FAMILY INFORMATION RESIDENCE ADDRESS CITY ZIP CODE PHONE FATHER'S FULL NAME OCCUPATION D.O.B. S.S.# / S.I.# ADDRESS (IF DIFFERENT THAN PATIENT'S) CITY ZIP CODE PHONE EMPLOYER BUSINESS ADDRESS CITY BUSINESS PHONE MOTHER'S FULL NAME OCCUPATION D.O.B. S.S.# / S.I.# ADDRESS (IF DIFFERENT THAN PATIENT'S) CITY ZIP CODE PHONE EMPLOYER BUSINESS ADDRESS CITY BUSINESS PHONE IN CASE OF EMERGENCY, NAME ADDRESS AND PHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW YOUR WHEREABOUTS: NAME ADDRESS PHONE AUTHORIZATION AND FINANCIAL RESPONSIBILITY IS YOUR CHILD COVERED BY A PRIMARY DENTAL INSURANCE PLAN? RECEIVED PREVIOUS CARE UNDER THIS PLAN YES NO YES NO NAME OF PARENT INSURED S.S.N./S.I.N. NAME OF INSURANCE GROUP/POLICY NO. PHONE NO. IS YOUR CHILD COVERED BY A SECONDARY DENTAL INSURANCE PLAN? RECEIVED PREVIOUS CARE UNDER THIS PLAN YES NO YES NO NAME OF PARENT INSURED S.S.N./S.I.N. NAME OF INSURANCE GROUP/POLICY NO. PHONE NO. IS YOUR CHILD ELIGIBLE FOR STATE/COUNTY AID? YES NO DOES EITHER PARENT HAVE A FLEX PLAN, THAT CAN BE USED FOR DENTAL/ MEDICAL EXPENSES THROUGH THEIR EMPLOYER? YES NO IF FAMILY NOT LIVING TOGETHER, PERSON TO BE RESPONSIBLE FOR CHILD'S ACCOUNT? THE PERMISSION OF PARENT OR GUARDIAN I GIVE DR. MOYER PERMISSION TO USE SUCH MEASURES AS DEEMED NECESSARY IN HIS/HER IS NECESSARY FOR DENTAL TREATMENT PROFESSIONAL JUDGMENT TO RENDER THE BEST DENTAL TREATMENT FOR MY CHILD. I ALSO GIVE OF A MINOR PERMISSION FOR PHOTOGRAPHS FOR DIAGNOSIS, TREATMENT PLANNING AND TEACHING. SIGNATURE RELATIONSHIP TO CHILD DATE PLEASE NOTE: PAYMENT IS EXPECTED FOR SERVICE RENDERED AT THE TIME OF THE FIRST VISIT. FINANCIAL ARRANGEMENTS FOR SUBSEQUENT TREATMENT MAY BE MADE FOLLOWING THE DIAGNOSIS. PAGE 3 of 3

4 Supplemental Patient Profile Please help us provide the optimum environment for your child. Child s Name: Date: 1. Does your child have any conditions that might affect him/her in a dental/orthodontic setting? 2. Could you tell us about how the condition affects behavior? 3. Please describe any significant fears or anxieties that your child may experience during visits to health care professionals (including dental). 4. Has the anxiety or fear prevented any necessary treatment? Please describe. 5. Are there any strategies that help your child open up to new experiences such as a visit to a new doctor? (Examples: show and tell, humor, going very slowly, modeling with parent or other sibling, other examples)? 6. Are there physical disabilities that need to be taken into consideration? (Example: Difficulty with fine motor skills). 7. How does your child deal with physical discomfort? 8. Are there learning disabilities that need to be taken into consideration? (Examples: Auditory processing difficulties, sensory integration dysfunction speech and language difficulties) 9. Any additional information that might help us provide a positive office experience for your child?

5 Privacy Policy Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice took effect on April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. Pediatric Dentistry, P.C. will use and disclose health information about you (or your child) for treatment, payment, health care operations and other uses. Treatment: We may use or disclose your (or your child s) health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your (or your child s) health information to obtain payment for services we provide to you or your child. Healthcare Operations: We may use and disclose your (or your child s) health information in connection with our healthcare operations. Healthcare operations may include quality assessment and evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Other Uses: Appointment Reminders: We may use or disclose your (or your child s) health information to provide you with appointment reminders, treatment options or services. These may include telephone reminders, messages, postcards or letters. Required by Law: We may use or disclose your (or your child s) health information when we are required to do so by law. National Security: We may disclose health information to Federal Officials, military authorities, correctional institutions or law enforcement officials. Abuse or Neglect: We may use or disclose your (or your child s) health information to appropriate authorities if we reasonably believe that you (or your child) are a possible victim of abuse, neglect, domestic violence or the possible victim of other crimes. We may disclose your (or your child s) health information to the extent necessary to avert a serious threat to your (or your child s) health r safety, or the health or safety of others.

6 Persons Involved In Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. Your authorization: Other uses or disclosures of health information not covered by this notice or the law that apply to us will be made only with your written authorization. If you give us authorization, you may revoke it in writing anytime. Your Family and Friends: We may only discuss your (or your child s) health information with others after you have given us written authorization. If a parent has sole custody, we will restrict discussing health info with the other parent upon receipt of court documents. PATIENT RIGHTS Access: You have the right to look at or request copies or your (or your child s) health information, with limited expectations. Your request must be in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You will be charged a reasonable fee for expenses such as copies, postage and staff time. Disclosure Accounting: You have the right to receive a list of instances in which we have disclosed your (or your child s) health information for purposes other than treatment, payment, healthcare operations and certain other activities after April 14, This request must be made in writing and you will be charged a reasonable fee. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your (or your child s) health information. We are not required to agree to these additional restrictions, but we will try to accommodate your request. If we do grant your request, we will abide by our agreement, except in an emergency. Alternative Communication: You have the right to request that we communicate with you about your (or your child s) health information by alternative means. You must make your request in writing and you must specify the alternative means. Amendment: You have the right to request that we amend your (or your child s) health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: You are entitled to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your (or your child s) privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or alternate locations, you may file a complaint with us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact: Privacy Officer W. Belleview Ave. Suite 110, Littleton, CO P: (303) / F: (303)

7 10184 W. Belleview Ave., Ste 110 Littleton, CO P: / F: Consent/Release: I authorize Dr. Moyer to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child/children s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (child/children s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist. In understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts and any portion not covered by insurance is due on the day of service. By signing this statement, I revoke all previous agreements to the contrary (excluding financial plans) and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor. Acknowledgment of Receipt of Notice of Privacy Practices My signature below constitutes my acknowledgement that I have been provided with a copy of the Notice of Privacy Practices. Patient/Parent or Guardian Signature Relationship to Patient(s) Date: Parent s Names: Children s Names: (Please list all) Home Address: City: State: Zip: Dad s Home #: Work #: Cell #: Mom s Home #: Work #: Cell #: Please list the number you would like to have your appointments confirmed at: IF YOUR INSURANCE HAS CHANGED, PLEASE NOTIFY THE FRONT DESK.

8 10184 W. Belleview Ave., Ste 110 Littleton, CO P: / F: Your insurance benefits Financial Information We are happy to help you receive your benefits from your dental insurance. It is important that you understand that as your child s dental care provider, our relationship is with you, not with your insurance company. While filing of insurance claims is a courtesy to our patients, all charges are your responsibility. We are in network for Delta PPO and Cigna PPO insurance. If you are not a part of these plans and your insurance allows you to go to any dentist, we will submit a claim for services. Our fees are considered to fall within the acceptable range of most insurance companies. However, some carriers use an arbitrary fee schedule, which bears no relationship to the current standard and cost of care in this area. The range of benefits depends solely on what your employer wishes to offer their employees. Some plans cover as little as 30% or as much as 100% for dental services, with most falling into the 50-80% range. Most plans exclude sedation services such as, nitrous oxide. Most insurance companies have limits on how often your child can receive some services. Our office is not responsible for monitoring your insurance contract limitations. Your insurance is a contract between you and your insurance company. Payments We accept MasterCard and Visa, cash or check. If you have dental insurance benefits, it is our pleasure to assist you in maximizing your insurance benefits by filing your dental claims with your insurance company. For all visits, we will collect the portion that we estimate your insurance will not pay. This is just an ESTIMATE on our part. Final amount owed will not be known until the claim is submitted and payment from the insurance is received. Any balance owed will be due upon your receipt of our statement. For families with no insurance, we require payment in full at the time service is rendered. If for any reason, we have not received your insurance carrier s payment 60 days after filing the claim, the balance will be due by you. Any account over 60 days old may be charged a fee of $25 and turned over to a collection agency if payment arrangements have not been made with our office. Should it be necessary, the undersigned agrees to pay all cost and expenses, including all attorney s fees or collection agency fees to affect collection of this account. I have read the above and understand the conditions of insurance and my financial obligations. Signature of Parent Date Patient Name