Patient Registration - Cochran & Soares Pediatric Dentistry

Patient Medical and Dental History

Child's Name*

Gender*

Male
Female

Child's Nickname

Age*

Date of Birth*

Pediatrician*

Pediatrician's Phone Number

Who may we thank for referring you?*

MEDICAL HISTORY:

Has your child experienced any of the following?:

Autism*

Yes
No

Anemia*

Yes
No

Asthma, Lung Disease or Breathing Problems*

Yes
No

Bleeding Problems, Hemophilia*

Yes
No

Cerebral Palsy*

Yes
No

Delayed Speech Development*

Yes
No

Developmentally Delayed*

Yes
No

Diabetes*

Yes
No

Thyroid or Glandular / Endocrine Problems*

Yes
No

ADHD / Behavioral or Learning Problems*

Yes
No

Fainting Spells*

Yes
No

AIDS, HIV Positive*

Yes
No

Heart Condition, Murmur*

Yes
No

Jaundice, Liver Disease, Hepatitis*

Yes
No

Kidney Disease*

Yes
No

Ear Infections, Hearing Loss or Impairment*

Yes
No

Special Needs, Mentally Handicapped*

Yes
No

Psychiatric Problems*

Yes
No

Seizures, Epilepsy*

Yes
No

Rheumatic Fever*

Yes
No

Sickle Cell Anemia*

Yes
No

Frequent Headaches*

Yes
No

Congenital Birth Defects*

Yes
No

Arthritis, Auto-Immune or Connective Tissue Diseases*

Yes
No

Cancer, Tumor, Leukemia*

Yes
No

Frequent Infections*

Yes
No

Eye Disease*

Yes
No

Hypertension, High Blood Pressure*

Yes
No

Any Other Medical History of Concern*

Yes
No

DENTAL HISTORY:

Do you have a dental related concern?

Yes
No

If Yes, Explain:*

Is your child experiencing any of the following?:

Cleft Lip / Palate*

Yes
No

TMJ/TMD Problems*

Yes
No

Latex Allergy*

Yes
No

Thumb / Finger / Pacifier*

Yes
No

List Food or Medication Allergy*

Problems Sleeping at Night*

Yes
No

Snoring*

Yes
No

Currently Using Bottle or Sippy Cup*

Yes
No

Currently Nursing*

Yes
No

Trouble Breastfeeding at Birth*

Yes
No

Please list any medications, vitamins or health supplements your child is currently taking:

Please complete the following questionnaire as thoroughly as possible. The information will be valuable assistance to us in establishing meaningful communication with your child.

Will your child be a cooperative patient? Explain:*

Favorite hobbies, games*

Does your child have any pets?*

Names of brothers and sisters*

School and grade*

Resposible Party Information

Name*

Address*

City

State

Zip

Phone

E-mail*

Date of Birth*

Occupation

Employer's Address

Spouse Information

Spouse's Name

Address(if different)

City

State

Zip

Phone

E-mail

Date of Birth

Occupation

Employer's Address

Consent

The signature affixed below authorizes examination and treatment by Drs. Setzer, Cochran, Soares and/or Drs. Setzer, Cochran, Soares and their staff, and further, use of those procedures which in the judgement of the doctor are necessary during the delivery of dental care.

I understand that Drs. Setzer, Cochran, Soares PA, may not be a contracted provider for my insurance company, and that our office will be filing to my insurance company as a courtesy and expect their payment in 30 days. I recognize that it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by the insurance company.

I hereby assign all dental and/or surgical benefits, to include major benefits to which I am entitled, including private insurance and other health plans to: Drs. Setzer, Cochran, Soares PA. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assigns to release all information necessary to secure the payment.

Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in regards to your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

May we request of your child's medical records for our references?*

Yes
No

May we forward information regarding your child's dental records to your primary care physician and/or Dentist?*

Yes
No

Name

This field is for validation purposes and should be left unchanged.