New Patient Paperwork-BryantPD

Child's First Name

Child's Last Name

Does the child have a preferred name?

Date of Birth

Child's SSN

Sex

Male

Female

Home Address

Who will be the responsible party for this patient?

Mother

Father

Other

Mother's Name

Mother's Phone Number

Mother's Date of Birth

Mother's SSN

Mother's Employer

Mother's Email

Father's Name

Father's Phone Number

Father's SSN

Father's Employer

Father's Date of Birth

Emergency Contact - Other than Parents

Emergency Contact Phone Number

Relationship to Patient

Does patient have dental insurance? *It is your responsibility to know if we are a network provider for your insurance plan.*

Yes

Who is the subscriber for the insurance?

Mother

Father

Self

Subscriber Employer

Subscriber ID Number

Insurance Company

How did you hear about our office?

Is this your child's first dental visit?

Yes

Does your child see any specialist other than a Pediatrician? If so, please list.

Does your child currently take any medications? If so, please list.

Has your child been hospitalized since birth? If so, please explain.

Does your child have any other medical condition not listed above? If so, please explain.

Does your child have any allergies? If so, please list.

Please list the names of anyone authorized to bring your child to their dental appointment:

Is there anything that we should know about your child prior to this appointment?

FINANCIAL POLICY STATEMENT:

Payment for services are due at the time of the visit unless other arrangements have been made. We accept cash, check, or identified credit cards. A service charge will be assessed on all returned checks.
First time patients being treated on an emergency basis must pay in full at the time of service.
We accept most traditional insurance policies. Patients with dental insurance must take care of their estimated portion not covered by the insurance at the time of treatment. If payment has not been received from the insurance company within sixty days of the original filing, the patient will be asked to pay the balance due and pursue reimbursement from their carrier.
We will file your insurance claims as a courtesy for you. Please be aware that some of the services provided may not be covered or may be considered above the “usual and customary.”
The office will assess account balances in excess of 90 days a monthly service charge of 1.5% per month of the unpaid balance. The office requires the patient to give at least a 24-hour notice of any appointment that needs to be rescheduled or cancelled. We will not allow you to reschedule a second appointment if your first appointment was broken. If you do not show up for any appointment, we reserve the right not to reschedule. Bryant Pediatric Dentistry will assess a rescheduling fee for any missed appointment.
In the case of an account balance in excess of 90 days, we reserve the right to turn you over to collections. If this situation occurs, you are responsible for paying the unpaid balance plus any collection fees and expenses that are incurred. Once your account has been closed and turned over to collections, you will no longer to able to schedule with our office.
MS CHIPS/MEDICAID/MAGNOLIA – I agree to pay for procedures not covered by the insurance program. I also understand the program has a maximum of $2,500 coverage and I will be responsible for charges over this amount.
If you make a treatment appointment for your child and you do not cancel or reschedule 24 hours before, you will be charged a no show fee of $50.

Do you agree to the Financial Policy above?

Yes

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose of Consent: By signing this form, you will consent to our use and disclosure for your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

Photograph Release: I agree that Bryant Pediatric Dentistry may use photographs of me or my child with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

Please type your name if you have read the above and give consent.