broadway patient registration

PATIENT REGISTRATION INFORMATION

Patient's First Name

Patient's Last Name

Today's Date

Nickname

Gender

Male Female

Birthday

Age

Grade

School

Name & ages of siblings

Address

City

State

Zipcode

Home Phone

Cell Phone

Email

Who has legal custody of patient?

Your relationship to patient:

Mother Father Guardian Other

Other

Father's Occupation

S.S.#

Employer

Phone

Mother's Occupation

S.S.#

Employer

Phone

Whom may we thank for referring you to us?

In an emergency, whom should we contact?

Name

Relationship

Phone

What is the reason for your child's visit?

How do you expect your child to react to his visit today?

Explanation:

FINANCIAL & INSURANCE INFORMATION

Relationship to Insured

Mother Father Both

Father's Name

Single Married Divorced

Address (If different than child)

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Employer

Soc. Sec. #

Birth Date

Email

Do you have dental insurance coverage for your child

Yes No

Insurance Company Name

Insurance Company Phone #

Insurance Company Address

City

State

Zip Code

Group #

Policy/ID #

Mother's Name

Single Married Divorced

Address (If different than child)

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Employer

Soc. Sec. #

Birth Date

Email

Do you have dental insurance coverage for your child

Yes No

Insurance Company Name

Insurance Company Phone #

Insurance Company Address

City

State

Zip Code

Group #

Policy/ID #

RELEASE AND ASSIGNMENT

I certify that my minor/child is covered by insurance with

Insurance Company

and assign directly to "That Broadway Smile" all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I also understand that if my insurance does not pay the portion within 60 days of my child's treatment, I will be responsible for full payment of the balance at that time. I hereby authorize "That Broadway Smile" to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, wherther manual or electronic.

Parent/Guardian Signature

Clear

Clear

Date

HEALTH HISTORY

Name of child's Physician

Phone

Address

Is your child in good health?

Yes No

Date of last physical exam

Has your child ever had a health problem?

Yes No

If so, what?

Has your child ever been hospitalized or had surgery?

Yes No

Please give reasons and dates.

Is there excessive bleeding when cut?

Yes No

Explanation:

Is your child allergic to anything?

Yes No

If so, what?

Is your child taking any medications at this time?

Yes No

Medication

Reason

Were there any complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions?

Yes No

If so, what?

Has your child been tested for the MTHFR gene mutation?

Yes No Unknown

Please check if your child has been treated for any of the following:

Other

Please elaborate on any items checked:

PHARMACY INFORMATION

Pharmacy Name

Pharmacy Phone

Pharmacy Address

DENTAL HISTORY

Has your child ever had a dental visit?

Yes No

Name of dentist

Did they have a positive experience?

THIS SECTION IS TO BE COMPLETED IF YOUR CHILD IS UNDER 10 YEARS OLD

Has your child been diagnosed with a lip/and or tongue tie?

Yes No

Has your child ever had a lip or tongue tie release?

Yes No

If so, Date

Has your child experienced any of the following issues? please check or elaborate as needed.

Which?

When?

How Long?

Which?

How Often?

FLUORIDE USE

Toothpaste Vitamins Rinse Water (NYC or Queens)

AUTHORIZATION AND FINANCIAL RESPONSIBILITY

Because your child is a minor, it becomes necessary that signed permission be obtained from a parent or guardian before any/all necessary services can be performed. I acknowledge that the above information is correct. I authorize the doctors and staff to take x-rays, photographs or other diagnostic aids deemed appropriate to make a thorough diagnosis and grant this office permission to provide my child's dental treatment. This consent is also valid for emergecy treatment, even in my absence. Furthermore, I understand that I am responsible for the cost of all dental care provided in this office.

Signature of parent or guardian

Clear

Clear

Date

Relationship to child

Witness

Acknowledgement of Receipt of HIPAA Policies and Procedures

Click on the hyperlink to obtain a copy:

That Broadway Smile's Notice of Privacy Practices

I have received and reviewed a copy of our dental practice's privacy, security and breach notification policies and procedures.

I understand that I should ask our dental practice's Privacy Official if I have any questions about these policies and procedures.

Patient's First Name

Patient's Last Name

Birth Date

Signature

Clear

Clear

Date

PATIENT REGISTRATION INFORMATION

FINANCIAL & INSURANCE INFORMATION

RELEASE AND ASSIGNMENT

HEALTH HISTORY

Please check if your child has been treated for any of the following:

PHARMACY INFORMATION

DENTAL HISTORY

THIS SECTION IS TO BE COMPLETED IF YOUR CHILD IS UNDER 10 YEARS OLD

FLUORIDE USE

AUTHORIZATION AND FINANCIAL RESPONSIBILITY

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