Welcome to Seattle Smiles Dental

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1 Welcome to Seattle Smiles Dental The Puget Sound Plaza TH Avenue, Suite 1230 Seattle, Washington TEL: FAX: MISSION Our mission is to provide exceptional, comprehensive dental care to our patients in a friendly and caring environment. We believe that a healthy mouth and smile is essential to a healthy body, and our focus is on prevention, early detection and education so our patients can achieve optimal oral health for a lifetime. We are committed to continuing our education and sharing our knowledge with each other and our patients. We strive to work together as a team, showing mutual respect and being mindful of each person s individuality. OFFICE HOURS Monday through Thursday 8 a.m. to 4:30 p.m. PARKING Parking is available in our building, the Puget Sound Plaza, with garage entry on the northwest side on Union St. There are several parking garages nearby, 2-hour metered street parking and major bus routes. ITEMS TO BRING Please bring your completed registration forms (or them in advance) or arrive 15 minutes early so you may complete them upon arrival. Bring a list of medications you are taking, the name and phone number of your physician, the name and phone number of your previous dentist and your dental insurance card (if applicable). Patients under 18 require a parent or guardian present to consent to treatment. You may also bring a copy of your most recent set of x-rays, treatment notes and plans. Please call us at least 2 business days in advance for any changes to your appointment date. WEBSITE Please visit our website at seattlesmilesdental.com for parking and driving directions and more detailed information. Please do not hesitate to call us with further questions.

2 YOUR CHILD'S INFORMATION Name (Last, First, Middle Initial) Social security # Date of birth Preferred name Female Male Address City State Zip Name of parent/legal guardian Cell phone Work phone I prefer to receive check-up notifications by: Mailed postcards Home phone The best number to reach me is at: Home Cell Work Other: Emergency contact name How did you hear about our office? Who may we thank for referring you? Phone # Date of last visit to dentist For what services? What is the reason for today's visit? Has child mentioned any dental problems? Any injuries to the mouth, teeth or head? Does child brush teeth daily? Any unhappy dental experiences? Does child floss daily? Intake fluoride in city water or supplements? Does or did the child experience/use any of the following? thumb sucking nail biting mouth breathing teeth grinding/clenching pacifier use sleeping with bottle tongue thrust speech problems Which describes your child's personality? friendly shy nervous strong-willed GUARANTOR INFORMATION (PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT) Name (Last, First, Middle Initial) Social security # Date of birth Address (if different) City State Zip Home phone Cell phone Employer s name Occupation Work phone Employer s address City State Zip Check if no dental insurance Primary dental insurance carrier Subscriber date of birth DENTAL INSURANCE INFORMATION Subscriber social security # Subscriber name Insurance phone # Insurance address Group # ID # City State Zip 3/2014-1

3 YOUR CHILD'S MEDICAL HISTORY Is your child under a physician s care? Physician s name If yes, for what condition(s)? Physician s phone number Physician s address City State Zip Has child ever been hospitalized or had a major operation? If yes, in bottom section explain and list dates. Females are you nursing, pregnant, or trying to get pregnant? Taking oral contraceptives? List all medications, pills, herbal supplements and drugs taken and for what condition(s): Are you allergic to any of the following? Aspirin NSAIDS/Ibuprofen Penicillin Codeine Metals Latex Local Anesthetics ne Other: What was your reaction? Does your child have (or had in the past) any of the following conditions? If yes, please explain below. AIDS/HIV Depression Liver disease Alzheimer s disease Diabetes Type 1 Type 2 Lung disease (COPD,emphysema) Anaphylaxis Drug or alcohol dependence Pacemaker Angina (chest pain) Epilepsy or seizures Parkinson s disease Anxiety or panic attacks Fainting spells/dizziness Psychiatric/mental illness Arthritis rheumatoid osteo Glaucoma/eye disorder Rheumatic fever Artificial heart valve Hay Fever/seasonal allergies Scarlet fever Artificial joint Headaches Shingles Asthma/breathing problems Hearing loss/impaired Sinus trouble Bisphosphonate medications Heart attack Sleep disorder Blood disorder (e.g., anemia/hemophilia) Heart trouble/disease Stomach/intestinal disorder Blood pressure low high Hepatitis A B C Stroke Bruise easily Herpes virus/cold sores Thyroid disease Cancer/tumor Hives or rash Tuberculosis Chemotherapy/radiotherapy Hypoglycemia Ulcers Chronic pain (e.g., back, neck) Jaundice Venereal disease Congenital heart disorder Kidney problems/dialysis Explain yes answers below. Also, please indicate any special concerns or provide additional information that may be useful in providing dental care for your child. Parent/Legal Guardian Signature Date Dentist Signature 3/2014-2

4 ACKNOWLEDGEMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICES I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Jenny Nguyen, DDS - Seattle Smiles Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Jenny Nguyen, DDS - Seattle Smiles Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me. By signing this agreement, I acknowledge the receipt and understanding of the Statement of Privacy Practices. In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the additional person(s) identified below. Printed name of patient Signature of patient or responsible party Date Relationship of responsible party to patient I authorize the following additional person(s) access to my account: Printed name(s) and relationship to patient 3/2014-4

5 FINANCIAL POLICY AND CONSENT TO DENTAL TREATMENT METHODS OF PAYMENT All fees are due and payable at the time treatment is rendered. We accept cash, personal checks, credit cards and debit cards (Visa, MasterCard or Discover). DENTAL INSURANCE The estimated patient copay and deductible for treatment must be paid in full on the date of service. For your convenience, we will file the necessary forms with your insurance company to help you receive the full benefits of your coverage. You will receive a statement regarding your account activity for any remaining balance. A 1.5% monthly finance charge will be assessed on all past due accounts. TREATMENT PLAN AND INSURANCE ESTIMATES If treatment is recommended, you will receive a treatment plan outlining our office fee, estimated insurance coverage (if applicable) and your estimated portion that will be due. Because we cannot guarantee your exact insurance coverage, you are ultimately responsible for fees generated by your treatment and any balance due after insurance payment. You will be able to authorize any changes to the treatment plan which may be necessary due to the unpredictable nature of certain dental procedures. OTHER PAYMENT OPTIONS We offer an extended payment plan through a 3 rd -party, Care Credit, upon qualification. downpayment is required, there are no pre-payment penalties, low monthly payments and no interest if paid in full within the promotional period. If interested, please discuss this option with our front office coordinator. RETURNED CHECKS AND CANCELED APPOINTMENTS Checks returned to our office from your financial institution are subject to a $25.00 returned check fee to your account. Canceled or rescheduled appointments within 2 business days or no show appointments will incur a $50 fee to your account. By signing this agreement, I consent to dental treatment by Dr. Nguyen and her staff. I assign directly to Seattle Smiles Dental all insurance benefits, if any, otherwise payable to me for services rendered. I am responsible for charges incurred for dental services to me or my dependents in this dental office. I authorize Dr. Nguyen and her staff to collect all information necessary (e.g., radiographs, photographs, periodontal charting, tooth records, written reports) to provide my dental care and to submit this information to my insurance if required. Printed name of patient Signature of responsible party Date Relationship of responsible party to patient 3/2014-5

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