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Welcome to Pediatric Dentistry of Ridgeland. Our staff would like to welcome you and your child to our dental office. We strive to

provide a fun and educational experience for your child while also maintaining the highest level of excellence in your child’s care and

treatment. Our ultimate goal is teaching good oral hygiene that will enable our patients to maintain beautiful smiles for a lifetime!

Please complete the detailed medical form. This information will allow us to provide your child with the safest comprehensive dental

care possible. Please feel free to ask questions about any item that is not familiar.

patient information

Today’s date:

Patient’s name: ________________________________________________ Nickname:

Home address: _________________________________________________ Home phone:

City: __________________________________________ State: ______________ Zip Code:

Date of Birth: _______________________Age: Social Security #: ○Male ○ Female

How did you find us? Email Address:

legal guardian information Mother’s Information: ○ Mother ○ Step Mother ○ Legal Guardian ○ Grandmother

Name: Date of Birth: Social Security #:

Address: City, State & Zip:

Home Phone: Cell: Work:

Occupation: Employer:

Father’s Information: ○ Father ○ Step Father ○ Legal Guardian ○ Grandfather

Name: Date of Birth: Social Security #:

Address: City, State & Zip:

Home Phone: Cell: Work:

Occupation: Employer:

emergency contact information In case of an emergency where either the parent or legal guardian can not be reached, please identify the following information for the

next closest relative not living with the patient.

Name: Relationship to patient:

Address: Phone:

consent for dental treatment I request and authorize Dr. Tiffany Green & her office staff to examine, clean & provide my child with comprehensive dental

treatment including fillings, crowns, extractions and nitrous oxide. I further request & authorize the taking of dental x-rays as may be

considered necessary by Dr. Tiffany Green to diagnose and/or treat my child’s dental condition. I will allow photographs to be taken

of my child and/or my child’s teeth for diagnostic & educational purposes. I understand that dental treatment for children includes

efforts to guide their behavior by helping them to understand the treatment in appropriate terms for their age. Dr. Tiffany Green will

provide an environment likely to help children learn to cooperate during treatment by using praise, explanation & demonstration of

procedures & instruments, & using variable voice tones. I understand that I will be responsible for any charges incurred on this child

for dental treatment.

Signature: Date:

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medical history Has your child ever had any of the following conditions?

Yes No Yes No

○ ○ Sickle Cell Anemia or Trait ○ ○ Measles, Mumps or Chicken Pox (when? _______)

○ ○ Bleeding Disorders/ Hemophilia ○ ○ Skin Disorder or Eczema

○ ○ Blood Transfusion (date(s) ) ○ ○ Tonsillectomy and/or Adenoidectomy (when? _____)

○ ○ Hypertension ○ ○ Chronic Ear Infections / Otitis Media

○ ○ Anemia ○ ○ Tuberculosis or Positive Test Result (when? _____)

○ ○ Heart Murmur (Innocent or Pathologic) ○ ○ Hepatitis (type )

○ ○ Tetralogy of Fallot ○ ○ Immunologic Disorder, HIV, AIDS, ARC

○ ○ Heart Condition ○ ○ Hearing Impairment (right, left or both)

○ ○ Rheumatic Fever ○ ○ Eye Problems (right, left or both)

○ ○ Bruises or Bleeds Easily ○ ○ Stomach or GI Disorder

○ ○ Cystic Fibrosis ○ ○ Chronic Constipation

○ ○ Asthma or Lung Problems (Inhaler, Nebulizer) ○ ○ Appendectomy (when? )

○ ○ Pneumonia (when? ) ○ ○ Thyroid Disorder

○ ○ Seasonal Allergies, Hay Fever, etc. ○ ○ Diabetes Mellitus (NIDDM or IDDM x day)

○ ○ Cancer, Malignancy, Leukemia, or Lymphoma ○ ○ Currently Pregnant

○ ○ Febrile Seizure, Fainting Spells ○ ○ Implanted Shunt

○ ○ Seizure Disorder, Epilepsy (last episode ) ○ ○ Premature Birth (weeks )

○ ○ Tobacco, Drug or Alcohol Use ○ ○ Cleft Lip/Palate (bilateral/unilateral)

○ ○ ADD, ADHD or Hyperactivity ○ ○ Congenital Birth Defects/Syndromes

○ ○ Emotional or Behavioral Problems ○ ○ Learning Disability

○ ○ Psychiatric Problems ○ ○ Autism

○ ○ Physical or Emotional abuse ○ ○ Cerebral Palsy, Muscular Dystrophy

○ ○ Neurological Disorder (Hydrocephaly, Microcephaly) ○ ○ Other Handicaps or Disabilities

○ ○ Kidney Disease or Transplantation ○ ○ Delayed Development, MR (approx. age child functions )

○ ○ Urinary Tract Disorder ○ ○ Any Hospitalizations

○ ○ Liver Disease or Transplantation ○ ○ G tube, Tracheotomy

Please list the names & phone numbers of any physicians that are currently treating your child.

Type of Physician Doctor’s Name Office Phone Number

Pediatrician

When was your child’s last medical check-up with his/her primary care physician?

Please list all medication(s) patient is currently taking:

Is your child allergic or ever experienced an adverse reaction to a medication? If yes please explain:

Does your child have an allergy to latex, foods or dyes? If yes please explain:

Other medical conditions not noted above:

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dental history

Yes ○ No ○ Has your child ever been treated by a dentist? Date of last dental visit?

Yes ○ No ○ A Pediatric Dentist? If yes, whom?

Yes ○ No ○ Has your child ever had dental x-rays? Date?

Yes ○ No ○ Does your child suck his/her thumb, finger, pacifier or blanket?

Yes ○ No ○ Does your child brush his/her teeth? Do you assist? How often?

Yes ○ No ○ Does your child floss his/her teeth? Do you assist? How often?

Yes ○ No ○ Does your child snack between meals?

Yes ○ No ○ Has your child been prescribed fluoride supplements?

How would you predict your child’s behavior to be today? ○Cooperative ○Nervous ○Defiant ○Don’t Know

What are your primary concerns regarding your child’s oral health and/or reason for today’s visit?

Has your child ever suffered from any of the following dental related problems?

Yes No Yes No

○ ○ Bad breath/Halitosis ○ ○ Popping or soreness of the jaws (right, left or both)

○ ○ Bleeding Gums ○ ○ Dental infection or abscess

○ ○ Stained or Discolored teeth ○ ○ Pain from teeth

○ ○ Cold sores or fever blisters ○ ○ Missing or extra teeth

○ ○ Dry mouth ○ ○ Previous injury or trauma to teeth, mouth or face

○ ○ Cavities If so please explain:

○ ○ Orthodontics

notice of privacy practice – HIPPA

Disclosure of Health Information

We use and disclose health information about your child for treatment, payment and healthcare operations. We may disclose your

child’s information to a healthcare provider treating him/her. You may give us written authorization to disclose health information to

anyone for any purpose. This may be revoked in writing. We need written permission before any health information is disclosed to

any caregivers besides the child’s legal guardian. In the event of an emergency we will disclose information based on our professional

judgment. We will not use health information for marketing purposes. If we suspect a possible victim of abuse, neglect, or domestic

violence we may disclose your child’s health information as the law requires. We may disclose your child’s health information to

provide you with appointment reminders or treatment recommendations (such as voicemails, postcards, emails or letters).

Patient Rights

Access: You have the right to look at or get copies of your health information. If you request copies we will charge you for each page

for staff time to locate and copy the information, and postage if you want the copies mailed.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of information.

Alternative Communication: You have the right to request that we communicate with you about your child’s health history in

alternative means.

Amendment: You have the right to request that we amend your health information. We may deny your request under certain

circumstances.

Questions and Complaints

If you are concerned that we may have violated your privacy rights, or disagree with a decision we made about access to your health

information or in response to a request to amend or restrict the disclosure of health information you may submit a written complaint to

the US Department of Health and Human Services. If you have any further questions about our privacy practices please contact

Dr. Tiffany Green.

Signature: Date:

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financial policy Please be aware that the parent/legal guardian bringing the child to our office is responsible for payment of all charges. We cannot

send statements to other persons. We ask that you pay the cost of the initial examination and any necessary dental x-rays on the day of

that appointment. Please understand that financial arrangements are made directly with you. For the convenience of our patients, the

following outlines our financial policies.

1. Payment is due in full for each appointment as services are rendered. We accept cash, personal checks, Visa, Mastercard,

American Express and Discover. A charge of $30.00 will be assessed on checks returned for any reason.

2. Dental Insurance: We are dedicated to providing all our patients with the finest treatment available and base our treatment

recommendations on what will be best for your child & not what your insurance company does or does not pay. Please read

the following in regards to dental insurance coverage.

1. We must emphasize that as a health care provider, our relationship is with you & not your dental insurance

company. Your dental insurance is a contract between your employer & the insurance company. Most plans

routinely pay between 50-75% of the average total fee for covered treatment.

2. As a courtesy, we will be happy to file your dental insurance. Any amount determined not to be covered by your

insurance company is payable at the time services are rendered; these fees may include deductible, co-

payments, certain procedures not covered by your insurance policy, and the difference between our fees and the

amount covered by your insurance company.

3. In the event your insurance carrier will not reimburse our office you will be responsible for the full cost of visits at

the time services are rendered and your insurance company will send you the reimbursement check directly.

4. We allow a maximum of 45 days for your insurance company to clear account balances. Any unpaid portions will

be due in full, by you, after this period.

3. Fillings: Our dental material of choice is a white (composite resin) filling. Please be aware that your insurance company

may not pay for a resin filling at the same level as a silver (amalgam) filling. In some cases, Dr. Tiffany may recommend

placing a silver crown instead of a resin filling.

4. Nitrous Oxide (laughing gas): Nitrous oxide is not always covered by dental insurance. We thank you for your payment on

the date of service.

5. Appliances: The entire cost of the appliance must be paid on the day that your child’s impressions are taken. This is

necessary because our office must pay laboratory bills when appliances are ordered, not when they are completed.

6. Emergency Treatment: All emergency treatment must be paid in full at the time the service is rendered.

7. Pre-treatment authorizations: Some insurance companies recommend an estimate of the work to be done and the fees to

be charged before determining their benefits to you. If so, we will provide you with the pre-treatment fee estimate. In this

case, it will be up to you to determine if you wish to proceed with the treatment before the insurance benefit is determined.

8. Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. An interest fee will

be charged for all debts 60 days past due. If we have to refer your account to a collection agency, you agree to pay all of our

incurred collection costs.

I have read & understand the above financial policy & that I must pay for services as they are rendered. The below dental

insurance information is for Pediatric Dentistry of Ridgeland, PLLC to assist me in filing for services that have been

rendered to my child. I understand that it is my responsibility to pay any portion of treatment that is not covered by my

insurance company.

Signature of person responsible for this account: Date:

dental insurance information

Primary policy holder: Name:

Date of Birth: Social Security #:

Insurance carrier: Name:

Claim Address:

Customer Service #:

Group/Policy #

Patient ID #

Employer of Insured: Company Name:

Address:

Phone #

Do you have secondary dental insurance? If yes, name of secondary policy