New Patient Registration Patient Details

New Patient Registration Contact Information

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  •  Email
  •  Home

New Patient Registration Emergency Contact Information

In case of an emergency, who should we notify besides guardian?

New Patient Registration Responsible Party's Information

Unless information is different, only complete this page for one child.

New Patient Registration Additional Parent/Guardian Information

New Patient Registration Primary Dental Insurance

New Patient Registration Secondary Dental Insurance

  •  By checking this box,

I authorize my insurance company to pay the dentist all insurance benefits rendered.

I authorize the use of this electronic signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits.

I understand that I am financially responsible for all charges whether or not paid by insurance.

New Patient Registration Child's Dental Information

  •  3+ a day
  •  Twice a day
  •  Once a day
  •  Weekly
  •  Seldom
  •  By parent
  •  By child
  •  Both
  •  Yes
  •  No
  •  Once daily
  •  Occasionally
  •  Never
  •  By parent
  •  By child
  •  Yes
  •  No
  •  Had complications from past dental treatment
  •  Had/has braces, orthodontic treatment
  •  Teeth are sensitive to hot, cold, biting, sweets or avoiding brushing any specific area
  •  Gums bleed when brushing or flossing
  •  Lip sucking/biting
  •  Uses a Pacifier
  •  Nail biting
  •  Finger/Thumb sucking
  •  Nursing/Bottle
  •  Grinds teeth
  •  Snores
  •  Have/ had pain in the jaw joint
  •  Mouth or chin injury
  •  Speech problems

New Patient Registration Medical History

  •  Yes
  •  No
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  •  No
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  •  By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature.

New Patient Registration Consent for Services and Financial Policy

Payment Options

Payment is due at the time of service. Any outstanding balance will be collected at the end of your child's appointment along with any co-pay. If you are a patient with no insurance or have an insurance we do not bill, you will be required to pay in full at the time of service.

We accept the following credit cards:

Visa, MasterCard, Discover, American Express and Care Credit

Insurance

Your insurance policy is a contract between you and your insurance carrier. Please review and understand your insurance benefits. Your specific policy may not cover everything. If you do have questions please contact your insurance company. Different policies from the same insurance company may have different requirements. Please be aware of what your policy covers and what it does not.

We ask that you are financially responsible for payment of all co-pays, deductibles, and non-covered services.

Non-sufficient Funds (NSF) Checks

If a check is returned because of non-sufficient funds, there will be a $40.00 NSF charge applied, plus the amount of the check.

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Consent for Services and Financial Policy.

New Patient Registration Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for Olympia Pediatric Dentistry. 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.

Olympia Pediatric Dentistry reserves the right to change the privacy practices that are 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 to me.

Additional Disclosure Authority

 

ln addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.

New Patient Registration Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

 

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

  •  I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. This will serve as my electronic signature.
(Please click below to draw/upload sign)
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