New Patient Form

Please complete all required fields before your first visit

New Patient Form Packet

Child's First Name *

Child's Last Name *

Patient's DOB *

Gender

Parent's First Name *

Parent's Last Name *

Phone *

Email *

Street Address *

City *

State *

Zip *

How did you hear about us? *

Pediatrician Information

Pediatrician's First Name *

Pediatrician's Last Name *

Pediatrician's Phone *

Medical History

Is your child on any medications? *

Does your child have any known medical problems? *

Any bad reaction to Novocaine or Laughing Gas? *

Allergies to Food or Medicine? *

Bleeding Problems? *

Describe Medical Issues If Any *

Is this your child's first dental visit? *

Reason for child's visit today *

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. We at The Little Teeth Workshop have been compliant since that date. This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.

We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

I have read and understand the HIPAA Privacy Notice and consent to the use and disclosure of my child's health information as described.

Financial Policy

Thank you for choosing The Little Teeth Workshop. We are committed to your child's successful treatment. Please understand that payment for services is part of that treatment. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment.

All patients must complete the Patient Registration form before seeing the doctor. We accept Cash, Checks, and all major credit cards. We also accept most dental insurance plans. If your insurance has not paid within 60 days the balance will be transferred to your responsibility. You will be expected to pay your estimated share at the time of service.

A $25 fee will be charged for returned checks. There is a $50 fee for missed appointments or cancellations with less than 24-hour notice.

I have read and agree to the Financial Policy of The Little Teeth Workshop.

General Consent for Treatment

I hereby authorize the dentist(s) at The Little Teeth Workshop to perform dental examinations, X-rays, and any dental treatment deemed necessary or advisable for the proper dental care of my child. I understand that any dental procedures carry certain risks and benefits, and that I have the right to ask questions about any proposed treatment.

I authorize the use of local anesthesia and other medications as needed during treatment. I understand that some patients may have adverse reactions to medications or anesthesia, and I will inform the dental staff of any known allergies or sensitivities.

I consent to the dental examination and treatment of my child at The Little Teeth Workshop.

Signature

Parent/Guardian Signature (Type Full Name) *