Child’s Full Name: - Carolina Kids Dentistry · Child’s attitude toward dentistry: Reason for...
Transcript of Child’s Full Name: - Carolina Kids Dentistry · Child’s attitude toward dentistry: Reason for...
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:enohP :sserddA emoH s’dlihC
City State Zip
Child’s Favorite Hobbies/Interests:
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Physician’s Address: Date of Last Exam:
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City State Zip
Child’s Current Height:
Parent/Guardian Name: Relationship to Patient:
Social Security Number: Date of Birth:
Employer: Work Phone:
Mobile Phone:
Parent/Guardian Name: Relationship to Patient:
Social Security Number: Date of Birth:
Employer: Work Phone:
Mobile Phone:
Email Address:
How did you find out about our office?
Emergency Contact/Friend or Relative Not Living with You
Name: Phone:
Address:
City State Zip
Insured’s Name: Relationship to Patient:
Insured’s Date of Birth: Insured’s Employer
Name of Insurance Co: Group Number:
I have received the following treatment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental plan benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or portion of such charges. To the extent permitted by law, I authorize release of any information relating to claims filed. I hereby authorize payment of the dental benefits otherwise payable to me directly to Bevin K. Malley, DDS, PA.
Signature of Insured:
Date:
Bevin K. Malley, DDS PABoard Certified Pediatric Dentist
5829 Phyliss Ln, Mint Hill, NC 28227ph: 704.790.0590 fx: 704.790.0593
email: [email protected] www.ckdentistry.com
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Does your child currently have/previously had any of the following health problems?
Allergies (Food, Dust, Drug, Unknown) High/Low Blood Pressure :tsil esaelp ,sey fI
Any Current/Recent Injuries
Childhood Illnesses
Rheumatic Fever/Rheumatic Heart Disease Blood Transfusion
Congenital Heart Disease or Heart Murmur Any prolonged Bleeding/Bruises Easily
?dedeen demerp ,sey fI Kidney or Bladder Problems
:ycamrahP fo emaN Tuberculosis or Pneumonia
:rebmuN enohP ycamrahP Liver Problems, Jaundice or Hepatitis
Glandular or Hormonal Problems Accidents or Severe Infections
Diabetes/Blood Sugar Problems Psychological or Emotional Problems
Arthritis or Rheumatism (painful, swollen joints) Any Pending/Recent Surgery
Convulsions, Seizures, Fainting or Epilepsy Speech, Learning or Hearing Disorders
Anemia or Blood Disorders
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(Please Indicate) If yes, please list any current medications:
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Please explain any other medical concerns/current medication(s):
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?ecitcarp rehtona morf )syar-x gnidulcni( sdrocer tnerruc yna evah uoy oD
?smelborp latned yna tuoba denialpmoc dlihc ruoy saH
Any injuries or surgeries to the mouth, teeth, head? If yes, please describe:
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Please check if your child has any of the following habits:
Thumb Sucking Mouth Breathing Pacifier Nail Biting Finger Sucking Grinding Other:
How does your child receive fluoride? Water Supply Dentist Toothpaste Vitamins Tablets None Other:
Child’s attitude toward dentistry:
Reason for visit today/chief concerns:
I hereby certify that all of the above information is correct and true. Because the above-named child is a minor, it is necessary that a signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment can be commenced. Furthermore, I will be responsible for any professional fees incurred for dental services for my child. I understand that I am responsible for all charges whether or not covered by insurance. All balances over 30 days are subject to a 1.5% per month finance charge.
Signed:
Date:
:tneitaP ot pihsnoitaleR
Bevin K. Malley, DDS PABoard Certified Pediatric Dentist
5829 Phyliss Ln, Mint Hill, NC 28227ph: 704.790.0590 fx: 704.790.0593
email: [email protected] www.ckdentistry.com
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