GET ACQUAINTED QUESTIONNAIRE

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1 Aparna Aghi, D.M.D., M.S. tel fax Assistant Professor Pediatric Dentistry UCSF School of Dentistry Martin Sinai Rayman, D.D.S. Diplomate American Board of Pediatric Dentistry Dentistry for infants, children and adolescents. a pediatric dental practice built on experience - constantly progressing through innovation and enthusiasm GET ACQUAINTED QUESTIONNAIRE CHILD S Complete Name Sex Age Nickname Birthdate Home Tel. Person responsible for this account: Mother FATHER S Name Zip Code Father Other Occupation Soc. Sec.. Name of Employer Bus. Address Zip Business Telephone How long with current business MOTHER S Name Occupation Name of Employer Bus. Address Business Telephone How long with current business Do mother, father and child live together? How Long Tel. Soc. Sec.. How Long Zip Tel. If no, please explain: Names, ages of siblings Do you have a dental insurance plan? Dual? FATHER MOTHER 1. Name of employee covered under this plan 1. Name of employee covered under this plan 2. Soc. Sec.. 2. Soc. Sec.. 3. Name and Address of Insurance Co. 3. Name and Address of Insurance Co. 4. Group or Policy. 4. Group or Policy. 5. Employee s birthdate 5. Employee s birthdate I hereby authorize direct payment (of the group insurance benefits otherwise payable to me) to Aparna Aghi, D.M.D. (Signed, Insured person) I hereby authorize direct payment (of the group insurance benefits otherwise payable to me) to Aparna Aghi, D.M.D. (Signed, Insured person) Name of former dentist, if any Telephone Address of last dental care Whom may we thank for referring you to our office? Address Telephone Name of parents dentist(s) PERMISSION FOR DENTAL TREATMENT I hereby give permission to APARNA AGHI, D.M.D., M.S., and/ or MARTIN S.RAYMAN, D.D.S. to render all necessary dental services and to use such methods and agents as he or she sees fit for the child named on this form and to contact the child s physician as necessary. I understand that no treatment will be started until the recommended treatment, time involved and financial investment have been discussed with me by either Dr. Aghi, Dr.Rayman, or one of the staff members, at which time I may void this permission if I so choose. I will be responsible for any bills incurred by this child for dental treatment. Signed (Parent or Guardian) PLEASE TURN OVER TO FILL OUT OTHER SIDE

2 MeDICaL 1. Family Physician or Pediatrician (If Kaiser, include patient number): Address: HeaLtH HIStOrY This information can be of great value to better understand your child. Telephone: 2. Is your child: In good general health right now? If NO, please explain: Sensitive or allergic to any drug including penicillin or local anesthetic? At present taking any drugs? List: Allergic to food, animals, latex, dust? Other: 3. Has your child ever been hospitalized? If yes, for what? 4. Any history or difficulty with any of the following: anemia, asthma, bone disorders, brain injury, excessive bleeding, convulsions, cerebral palsy, diabetes, epilepsy, fainting or dizziness, hearing, hepatitis, heart trouble, cancer or malignancies, rheumatic fever, or premature birth or intubated? If yes please circle above and explain in more detail: 5. Are there any learning problems? 6. How would you expect your child to behave in our office? 7. Would you describe your child as (please circle) shy, frightened, apprehensive, outgoing? 8. Is there something special you d like us to know about your child and/or family? DeNtaL 1. Is this an emergency visit? 2. Is this the first visit to the dentist? 3. Has any member of your family previously been a patient of this office? Names and ages: 4. Present dental problem as you see it (if any): 5. Has your child complained about dental problems? 6. Has your child had any unhappy experiences with dental care? 7. Is your child s attitude towards dentistry good? 8. Any mouth habits: thumb sucking, pacifier, nail biting, finger sucking, grinding? 9. Has your child had any history of cavities, toothaches, pain, broken teeth, extracted teeth, gum infections, missing permanent teeth or extra permanent teeth? If yes, please circle condition(s) above. 10. Has your child ever had an injury to the head, mouth or teeth? Describe: 11. First tooth erupted at about how many months old? 12. At what age was your child weaned from the breast or bottle? 13. Name your child s favorite toy, hobby, TV show, etc. 14. School attends: 15. When and how often does your child brush? 16. Do you assist your child with brushing? 17. How often is dental floss used? 18. Is fluoride taken? If yes, circle all that apply: drops tablets vitamins toothpaste gel rinse 19. Have mother and/or father had much tooth decay? 20. Has either parent had difficulty getting numb for dental treatment? 21. Do you use tap, filtered or bottled water for cooking and/or drinking? Circle all that apply. Reviewer s Initials

3 APARNA AGHI, D.M.D. Dear Parents: Infant, Child & Adolescent Dentistry PARENT GUIDELINES You may choose whether to accompany your child to his/her filling appointment. Although we sense that some children do better without parents present, we encourage you to be with your child. If you choose to be present, we suggest the following guidelines to improve chances of a positive outcome. Please: 1. Allow us to prepare your child. 2. Be supportive of the practice s terminology. a. In words your child can understand, we will tell your child what we are going to do, show them what we will use, and do the procedure in as non-threatening and comfortable a manner as possible. b. We are selective in our use of words. Please support us by NOT using negative words that are often used for dental care. For instance, instead of: shot or needle we say metal straw or sleepy juice hurt we say pinch drill we say water whistle pull or yank tooth we say wiggle a tooth out Please avoid saying It is not going to hurt. Your child may focus on this suggestion of discomfort. 3. Be a silent observer support your child with touches like hand-holding, etc. a. This allows us to maintain communication with your child. b. Children will normally listen to their parents instead of us and may not hear our guidance. c. You may give misleading or incorrect information. 4. If asked to leave, be ready to walk away, out of your child s field of vision. You will be invited to sit back down when your child is, once again, actively helping. a. Many children will try to control the situation. b. Acting out is normal but can be unacceptable during fillings. c. We will continue to support your child at all times and you can observe (out of your child s line of vision). 5. We have an imaginary red button. If at any time, you feel uncomfortable with the situation, please let us know. Similarly, we may determine it to be advisable to stop treatment. In either case, we will discuss the situation and if necessary temporize the tooth(teeth) so that you and your child may leave, and return when we both feel it is advantageous. You can actively help in these important ways to ensure the success of your child s visit. We are confident that all will go well and hope these guidelines will prepare you with confidence for the upcoming appointment. Thank you, Dr. Aghi Dr. Rayman & Staff

4 APARNA AGHI, D.M.D. Infant, Child & Adolescent Dentistry CONSENT FOR EMERGENCY MEDICAL OR DENTAL TREATMENT California Civil Code, Section 25.8 expressly provides that a parent may authorize an adult into whose custody a child is entrusted to consent if necessary, to medical and dental treatment: Either parent, or a guardian having legal custody of a minor may give written authorization for an adult into whose care the minor has been entrusted to consent to X-ray examinations, anesthesia, medical or surgical diagnosis, and/or treatment and hospital care to be rendered to said minor under the general or special supervision and advice of a physician or surgeon licensed under the provisions of the Medical Practice Act, or to X-ray examinations, anesthesia, dental and/or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act. AUTHORIZATION In accordance with the provisions of Section 25.8 of the California Civil Code, I hereby authorize to procure medical, hospital, or dental care for my child(ren) Name(s) in the event of injury or illness while the child(ren) is(are) in the care of the above named facility or person(s). (I understand and agree that I am financially responsible for any care so provided). Signature of Parent or Guardian Physician's Name: Address: Telephone #: Medical Record #: Dentist's Name: Aparna Aghi, D.M.D., M.S. Dentistry for Children and Adolescents Address: 912 Grand Ave., Suite 202 San Rafael, CA Telephone #: (415) Fax #: (415)

5 tice of Privacy Practices This notice describes how your child s health information may be used and disclosed and how you can access this information. Please review it carefully. At the office of Aparna Aghi, D.M.D., we have always kept your child s health information secure and confidential. A new law requires us to continue maintaining your child s privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your child s health information to those involved in his/her treatment. For example, a review of your file by a specialist doctor whom we may involve in their care. We may use or disclose your child s health information for payment of our services. For example, we may send a report of your child s progress to your insurance company. We may use or disclose your child s health information for our normal health care operations. For example, one of our staff will enter you and your child s information into our computer. We may share your child s medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy. We may use your child s information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your child s appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone. In an emergency, we may disclose your child s health information to a family member or another person responsible for your child s care. We may release some or all of your child s health information when required by law. If this practice is sold, your child s information will become the property of the new owner. Except as described above, this practice will not use or disclose your child s health information without your prior written authorization. You may request in writing that we not use or disclose your child s health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your child s health information beyond the above normal uses. As we will need to contact you and your child from time to time, we will use whatever address or telephone number you prefer. You have the right to transfer copies of your child s health information to another practice. We will mail your child s files for you. You have the right to see and receive a copy of your child s health information, with few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your child s records, we may charge you a reasonable fee for the copies. You have the right to request an amendment or change to your child s health information. Give us your request to make changes in writing. If you wish to include a statement in your child s file, please give it to us in writing. We may or may not make the changes you request, but we will be happy to include your statement in your child s file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information. You have the right to receive a copy of this notice. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, D.C You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your child s health information privacy, please contact our Privacy Officer, Dr. Martin Rayman at This notice goes into effect as of April 9, Acknowledgement I have received a copy of the Aparna Aghi, D.M.D. tice of Privacy Practices. You may refuse to sign this acknowledgement. Signed Print Name Please note the name of the patient

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