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Please Note:
YOU MUST RECEIVE A "THANK YOU" PROMPT AT THE END OF COMPLETING THIS FORM
The "thank you" prompt confirms that your form has been submitted properly.
This electronic form is protected with 128-bit SSL encryption.
No information is being stored online.
All your information will be kept in your child's digital chart in our office.
Your privacy is important to us.
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Family Information

April 23, 2018


    

     






Do you have any other family members treated in our practice?  
Anyone we may thank for referring you?  

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Medical History - Part I

Do you have Pediatrician or Family Physician?  

     
Does your child receive regular medical examinations?  
Is your child in good health?  
Is your child up-to-date on required vaccinations?  
Was pregnancy and delivery normal?  
Was your child adopted?  
Is your child under medical care at the present time?  
Is your child presently taking any medications?  
Is your child allergic to any food?
 
Please, provide the list:
Is your child allergic to any medications?
 
Please, list below:
Does your child have any environmental allergies?  
Is your child allergic to latex?  

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Medical History - Part II

Has your child ever been hospitalized?  
Has your child ever received general anesthesia?  
Any complications?  

Have you ever been told that your child requires antibiotics prior to dental treatment?
 

Has your child had any history of or difficulty with the following:














































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Dental History - Part I

Is this your child’s first visit to a dentist?

Any unhappy or unpleasant dental experience?
Does your child have any dental / oral pain?
Any history of injury to mouth, teeth, or head?
Has your child ever had dental x-rays?
Has your child ever seen an orthodontist?
Does your child wear a mouthguard for sports?
Does your child receive Fluoride tablets/drops?
Does your child use toothpaste while brushing teeth?


What type of water does your child drink?
       
 


Does any of the following apply to your child (check all that apply):

















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Dental History - Part II

Please list any questions, concerns, requests, or comments you may have:

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and any requests for sharing of this information with other parties must be done in writing. I give my consent for needed dental services which may include topical fluoride, necessary x-rays, local anesthetic, nitrous oxide analgesia, also known as laughing gas, and the use of proper and acceptable methods to complete treatment.  All treatment will be discussed with me by the doctors prior to be rendered.  I understand that payment is expected at time of treatment. You may pay using major credit cards, cash, and Apple Pay.  NO personal checks. If we participate with your insurance carrier, our office will file an insurance claim for you. However, you will be responsible for any remaining balance not paid by your insurance carrier at the time of service.

If at any point you or your family is dissatisfied with the services provided at Summerfield Pediatric Dentistry, please notify Dr. Vali immediately to discuss your concerns further.

April 23, 2018       Dear guardian, your signature will be requested in the office
Date

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Electronic Communication Program

Dear Parent,

At Summerfield Pediatric Dentistry we strive to be as environmentally friendly as possible. To achieve this,we ask you to provide us information as to how we can respectfully communicate with you in regards to scheduled and check-up appointments. We can simply send you an email and/or a text message, if you choose, to remind you of your child’s upcoming appointment.

We will never sell, distribute, or forward your information to any third party. We value your family as patients and strictly adhere to state and nationally mandated HIPAA regulations. Being a parent is challenging and we know that you are busy. We hope to lessen your load with our electronic communication program.

Please check the boxes below that apply and kindly provide the necessary information.

We look forward to communicating with you electronically.








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Financial Policy

PATIENT NAME: ________ ___________     BIRTHDATE: _________ __, ____

Person financially responsible for your child’s account:
Phone #
     

PAYMENT: We value our patients and strive to offer several payment options. Kindly, we request that fees for treatment are due in full and payable at time of service. For your convenience, we honor Master Card, Visa, American Express, and Discover cards.

PAST DUE ACCOUNTS: A finance charge of 1.5% per month or 18% per annum is applied to all balances over 90 days past due. Should your account be turned over to a collection agency or attorney, a 20% collection fee will be added to your account in addition to any other collection fees, court costs or attorney fees incurred. In case of suit, you agree the venue shall be in Westchester County, New York.

WAIVER OF CONFIDENTIALITY: In any external collection action regarding your account, your file may become a matter of public record.

CHECKS: Our office no longer accepts personal checks.

DENTAL INSURANCE: Insurance policies are contracts between the insurance company and you. It is the policy of our office to make financial arrangements with you directly, since you are responsible for treatment charges. Our office will submit a completed insurance form for you to your insurance company. We assume no responsibility for the amount of insurance coverage or any delay in reimbursements.

AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS: I authorize Summerfield Pediatric Dentistry, PC to release to my insurance carrier such protected health information as may be necessary for the completion of my treatment claims, assign to Summerfield Pediatric Dentistry, PC benefits for such claims, and agree to be responsible for any balance remaining after payment of such claims. In consideration for the professional services rendered to me, or at my request, I agree and understand the above, and give consent for services.This represents signature on file for your preferred provider.

April 23, 2018       Dear guardian, your signature will be requested in the office
Date

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Insurance Information

Dear Parent,

We are pleased to submit insurance claims on your behalf.

Please be advised that insurance companies do not cover 100% of services rendered. Every effort will be made by our office staff to make sure that you are informed of additional fees. Our office personnel will be more than happy to review your benefits with you so that there are no surprise charges. Please understand that unforseen charges or denials by insurance companies are out of our control.

If you receive a bill that you feel is an error or have questions about procedures that were not covered by your insurance provider, we ask you to kindly inform us by email or telephone at your convenience. Our trained insurance liasons will do their best to lessen your financial responsibility by working closely with your insurance providers.  The staff at Summerfield Pediatric Dentistry strives to make your experience a pleasant one.





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HIPAA



ACKNOWLEDGEMENT OF RECEIPT

OF NOTICE OF PRIVACY PRACTICES

I, , have reviewed a copy of this office's Notice of Privacy Practices.

**You May Refuse to Sign This Acknowledgement**

April 23, 2018       Dear guardian, your signature will be requested in the office
Date










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