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Call Us!
Meet Us
Meet Dr Davis
Meet The Team
Office Tour
Orthodontics
Treatment Options
Consultation And First Time Visit
Invisalign
Braces
Children’s Dentistry
Sedation
Patient Information
FAQ
New Patient Forms
Patient Registration
Insurance Information
Links of Interest
Locations
Blog
Contact Us
Call Us!
New Patient Forms
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2019-06-28T13:05:48-06:00
Welcome to Star Orthodontics and Pediatric Dentistry
Patient Information
Step 1 of 3
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Patient Name
*
First
Middle
Last
Home Phone
*
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
*
MM
DD
YYYY
Age
*
Sex
*
M
F
Prefer Not To Answer
Your Contact Email
*
Enter Email
Confirm Email
Select One
*
Mother
Stepmother
Father
Stepfather
Guardian
Name
*
Address
*
City, State, Zip
*
Email Address
*
Occupation
*
Employer
*
DOB
*
Social Security #
*
Parents Are
*
Married
Separated
Divorced
How Did You Hear About Us?
*
Additional Information
Please Add me to Text Message Alerts
Star Orthodontic and Pediatric Dentistry uses text messages to your cell phone to confirm appointments, office promotions, appointment changes, and appointment information. These messages will only be prompted by office administrators. Your number will not be shared with any outside parties.
Phone Numbers to Text
Carrier
(Example: Verizon)
Emergency Contact Info
Name
*
Phone
*
Relationship to Patient
*
E-Signature
I hereby guarantee payment of all charges incurred for this account. I understand that my insurance, if any, can be applied to my bill. If there is a balance on my account not covered by insurance, I agree to pay this amount. If it becomes necessary to collect this account, I agree to pay any additional costs of collections including attorney fees. I hereby consent to treatment by STAR Orthodontics and Pediatric Dentistry, Dr. J. Eric Davis and assign all benefits for dental treatment and services to be paid directly to named Doctor. I hereby authorize the release of any dental information required by insurance companies in connection with above assignment.
*
I agree.
Dental History
Child's Name
*
Why are you bringing your child to the dentist today?
Is your child currently having dental pain?
*
Yes
No
Has your child had a serious/difficult time with previous dental treatment?
*
Yes
No
Does your child drink floridated water?
*
Yes
No
Does your child currently or have they evert taken fluoride supplements?
*
Yes
No
Does your child brush his/her teeth daily?
*
Yes
No
Does your child floss his/her teeth daily?
*
Yes
No
Has your child ever had pain-tenderness in his/her jaw joint?
*
Yes
No
Has your child ever had trauma to their face or teeth?
*
Yes
No
Does your child frequently get cold sores, blisters, or any other oral lesions?
*
Yes
No
Has your child ever had orthodontic treatment?
*
Yes
No
Has your child ever had oral surgery?
*
Yes
No
Are you satisfied with the appearance of your child's teeth?
*
Yes
No
Is there anything else about having dental treatment you would like us to know?
*
Yes
No
Have you been told your child requires antibiotics prior to dental treatment?
*
Yes
No
Medical History
Child's Physician
*
Physician's Phone #
*
Is your child currently being treated by a physician for ANY medical condition?
*
Yes
No
If yes, for what condition?
*
Are immunizations current?
*
Yes
No
Please list ALL prescribed and non-prescribed (over the counter) medications your child is taking.
*
Name, Dosage, Times per Day
Des your child have any drug or food allergies? If yes, please list.
*
If none, type N/A
Is your child allergic to penicillin?
*
Yes
No
Is your child allergic to latex, plastic, peanuts, or any metals?
*
Yes
No
For Females: Are You Pregnant?
*
Yes
No
Taking Birth Control?
*
Yes
No
Check the following if your child has these medical problems.
Abnormal Bleeding
Anemia
Artificial Heart Valve
Asthma
ADHD
Autism
Birth Defects
Blood Transfusion
Cancer-Chemotherapy
Cerebral Palsy
Cleft Lip/Palate
Congenital Heart Defect
Developmental Delay
Diabetes
Ear or Hearing Problems
Epilepsy
Feeding or Eating Problems
Fever Blisters
Genetic Disorders
Growth Problems
HIV/AIDS
Hay Fever
Heart Murmur
Heart Surgery
Hemophilia
Hepatitus
Kidney Problems
Liver Disease
Mitral Valve Prolapse
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Speech Difficulties
Tuberculosis
Has your child been hospitalized?
*
Yes
No
Date & Details of Hospitalization
Does your child have asthma?
*
Yes
No
Last Asthma Attack?
Hospitalized from Asthma attack?
Yes
No
I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any change in my child's medical status. It will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need. I assign the doctor all medical benefits.
*
I agree.
Date
*
Date Format: MM slash DD slash YYYY
Pediatric Dentistry Consent and Acknowledgement of Receipt of Information
I authorize the dentist to use photographs, radiographs, and other diagnostic aids for the purpose of teaching, research and scientific publications.
*
Initial
The original screening of the treatment plan may be modified during the treatment for the best interest of the child as per the discretion of the dentist.
*
Initial
Broken Appointment Policy: I acknowledge that any cancellation and/or rescheduled visits with less than 24hr notice will incur a $60 broken appointment fee/ or patients will be placed on a "walk in" status only appointments.
*
Initial
Financial Responsibility: I am aware that I am fully responsible for any financial portion that my insurance deems is my responsibility. I further understand that should my balance remain unpaid and a collection agency is required, I will be responsible for any third party collection fees.
*
Initial
Warranty: Restorative dental work includes a warranty period of one (1) year when the patient adheres to the recommended instructions provided by a doctor including, but not limited to, dental check-ups, cleaning, and dietary restrictions.
*
Initial
The following person(s) are authorized to have full disclosures of your child's dental information, and are also authorized to bring my child to his/her dental appointments. He/she may consent for the recommended dental treatment and/or any changes in dental treatment. As well as he/she may consent to any medical decisions as necessary in the event of a medical emergency.
Name and relationship
Name and Relationship
Name and Relationship
I hereby state that I hav read and understand this consent, and that all questions to the above have been answered in a satisfactory manner; and I understand that I have the right to be provided with the answers to questions which may arise during the course of my treatment. I further understand that this consent will remain in effect until such time as I choose to terminate it.
*
I agree.
Consent of parent/guardian or authorized representative RESPONSIBLE PARTY
Date
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
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