375 Sixth Street Dover, NH Tel (603)

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1 375 Sixth Street Dover, NH Tel (603) Hello from JD Howard Dental! On behalf of all the staff, we welcome you to our office. We are happy that you have selected us to care for your dental needs. We want you to know that we are committed to providing you the highest quality of oral health care in the most gentle, efficient and caring manner possible. We will strive to always be on time for you, except as emergency situations arise. We will appreciate the same courtesy. If you do need to cancel your appointment we need at least 2 business days so that we have enough time to re-schedule your opening in the schedule; otherwise a $35 fee will be charged to your account (unless you paid the $35 depositthat would be used). We ask that you bring your x-rays from your previous dentist to your appointment. In many cases, your x-rays may be able to be ed to us which makes it easier for you, the other office and us! Our address is Please let your previous dentist know that you need them so they have plenty of time to get them to us. We can't diagnose without them. Our operatories are not big enough for any siblings to stay with you. Due to the sensitivity of our dental equipment and liability & safety issues, we ask that you have your sibling(s) stay in the waiting room with adult supervision. Or, we offer free childcare and would love to play in the kid's room with them! Enclosed you will find a Health History questionnaire. Please have mom or dad read and complete it and bring it with you to your first visit. Should you have dental insurance, please have mom or dad bring your insurance identification card with them. Feel free to check out our website at You can also us at with any non-emergency questions or concerns. We make it a priority to respond to the same day or within 24 hours. Also, we're on Facebook- we'd love for you to Like us! If you have any questions, or in case of an emergency, mom or dad may call us at (603) We are looking forward to a relaxed and pleasant visit with you! Sincerely, Joshua D. Howard, DMD and Associates P.S. Please don t forget to obtain your updated x-rays from your previous dentist.

2 Welcome to JD Howard Dental! Tell Us About Your Child Today s Date: Child s Name: Child s D.O.B.: / / Child s Age: Last First MI Nickname: Male Female School: Grade: Child s Home Address: Street City State Zip Parent s Information Parent s Marital Status: Married Divorced Separated Widowed Remarried Single Partnered MOTHER D.O.B.: / / Home Phone #: ( ) Work #: ( ) Cell #: ( ) address: Name: Social Security #: Address: Street City State Zip Employer: FATHER D.O.B.: / / Home Phone #: ( ) Work #: ( ) Cell #: ( ) address: Name: Social Security #: Address: : Employer: PRIMARY INSURANCE Policy Holder s Name: Street City State Zip Dental Insurance Information Relationship to Patient: Policy Holder s D.O.B.: / / Member/Subscriber ID: Group #: Ins. Co. Name: Phone #: ( ) Ins. Co. Address: SECONDARY INSURANCE Policy Holder s Name: PO Box/Street City State Zip Relationship to Patient: Policy Holder s D.O.B.: / / Member/Subscriber ID: Group #: Ins. Co. Name: Phone #:( ) Ins. Co. Address: PO Box/Street City State Zip

3 Dental History Is the child currently in pain? Yes No What is the primary reason for today s visit? Has the child experienced problems with previous dental work? Yes No Does the child brush his/her teeth daily? Yes No Floss his/her teeth daily? Yes No Previous/Present Dentist: Date of Last Visit: Why did you leave your previous dentist? What did you like most about any dentist you have seen? Least? Does/did the child have any of the following habits? Yes No Lip Sucking/Biting Yes No Clenching/Grinding Teeth Yes No Tongue/Cheek Biting Yes No Mouth Breather Yes No Thumb/Finger Sucking Yes No Nail Biting Yes No Used Pacifier Yes No Speech Problems Yes No Chewing on Objects Yes No Nursing Bottle Habits Yes No Tongue Thrust Yes No Breast Fed Medical History Child s Physician: Phone #:( ) Date of Last Visit: Address: Street City State Zip Is the child currently under the care of a physician? Yes No please Explain: How is the child s current physical health: Good Fair Poor Are immunizations current? Yes No Please list all drugs the child is currently taking: Besides the following, please list all drugs and/or things that cause the child allergic reactions: Latex? Yes No Metals/Nickel? Yes No Penicillin? Yes No Anything you would like to discuss with the Doctor in private? Yes No Yes No Abnormal Bleeding Yes No Convulsions Yes No Kidney Problems Yes No AIDS/HIV+ Yes No Diabetes Yes No Liver Problems Yes No Tonsillitis Yes No Epilepsy Yes No Low Blood Pressure Yes No Anemia Yes No Handicaps/Disabilities Yes No Lupus Yes No Any hospital stay/operations Yes No Hearing Impairment Yes No Measles Yes No Asthma Yes No Heart Murmur Yes No Mitral Valve Prolapse Yes No Blood Transfusion Yes No Hemophilia Yes No Mononucleosis Yes No Cancer Yes No Hepatitis Yes No Rheumatic Fever Yes No Chicken Pox Yes No High Blood Pressure Yes No Scarlet Fever Yes No Congenital Heart Defect Yes No Hives Yes No Sickle Cell Anemia Yes No Skin Rash Yes No Tuberculosis Yes No Other: I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my child s medical status. I authorize the dental staff to perform the necessary services that my child may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services, any deductible, and co-payment that my insurance does not cover. Signature Date For office use only: Dr s Initials Hyg./Assist Initials

4 Our Office Policies Insurance: As a courtesy to our patients, we will submit all claims to your insurance company. We do our best to determine covered benefits & expenses. However, because each policy is different, it is ultimately up to the patient to check with their insurance to determine the covered and allowed benefits. Any portion of treatment not covered by the insurance is the responsibility of the patient. We are in network with Delta Dental and Cigna. Any other insurance is considered Out of Network, but we will submit the claim for you. Estimates: We do our best to determine an estimate of your insurance benefits based on the recommended treatment and the information provided by your policy. Please note that these amounts are estimates done to the best of our knowledge and ability, coverage and benefits may vary depending on the determination of the insurance company. Payment: All deductibles, co-pays, and patient portions determined to be not covered by insurance are due at the time of service. Patients without insurance are expected to pay for treatment in full at the time of service. Payments: We accept cash, check*, money order, Visa, Mastercard, and Discover. As a courtesy our office offers CareCredit as a type of payment plan. If you are interested in using CareCredit as a type of payment, please ask a team member for more information or go online to *There is a $30 charge for returned checks. Delinquent Accounts: Should your account be in delinquency for over 60 days, it will be placed into collections. The patient is responsible for the legal and collection fees, as well as the total amount owed toward the account, and any interest it has acquired. The patient will not be seen in our office until the account is in good standing. If you are experiencing financial hardship and fear your account cannot be paid at this time, please contact our office manager. Broken Appointments: Our office reserves the right to charge a fee of $35-$50 for any broken or missed appointment, depending on the length of time reserved for the appointment. This must be paid before your next appointment. Please give us 2 business days notice if you cannot make an appointment. If multiple appointments are broken or missed we reserve the right to dismiss you from our practice. I have read, understood and agreed to the above policy for patient financial obligations. I understand that as part of the HIPAA Privacy Notice my account may be discussed by employees of JD Howard Dental, LLC with insurers, collection agents, 3 rd party billing services or legal entities. I understand that the care rendered to me by the doctor is based on my dental needs and I am responsible for the payment of those services. As a courtesy to me, the office team will assist in maximizing my dental insurance benefits and will process the insurance claims. However, I know that I am responsible for any services not covered by the insurance company. (Please Print Patient s Name) (Please Print Name of Responsible Party) Signature of Responsible Party (Parent/Guardian if Patient is a Minor) Date

5 CONSENT TO DISCUSS TREATMENT AND ACCOUNT I hereby authorize the following person(s) to have access to my account and to discuss any treatment in my chart. (Name) (Relationship) (Name) (Relationship) (Name) (Relationship) Patient s Name Patient/Guardian's Signature Date

6

7 Failed/Cancelled Appointment Policy Due to the increased number of failed appointments and appointments cancelled without 2 business days notice, we feel the need to implement this policy as follows: 1 st Failed/Cancelled Appointment: You will receive a phone call stating you failed/cancelled your appointment. A note will be made in your account. 2 nd Failed/Cancelled Appointment: You will receive another phone call stating you failed/cancelled your appointment again; a $35/$50 (depending on type of appt.) Failed/Cancelled Appointment fee will be charged; and a note will be added to your account. This charge must be paid in full in order to schedule any future appointments. This can be done over the phone with a credit card for your convenience. 3 rd Failed/Cancelled Appointment: You will receive another phone call, another $35/$50 Failed/Cancelled Appointment charge that must be paid in full before re-scheduling, and a note will be added to your account. You may be discharged from the practice at this time.

8 JD Howard Dental, LLC 375 Sixth St., Dover, NH Health Insurance Portability and Accountability Act of 1996 Notice of Privacy Practices Effective April: 14, 2003 Last Modified: July 10, 2012

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