New Patient Form

Patient Form

Patient Information

Gender: 
Phone Type
OK to leave message?

Parent / Guardian Information

Parent 1

Marital Status
Relation to Child:
Phone Type:
Phone Type:

Parent 2

Marital Status
Relation to Child::
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Has your child visited an orthodontist before? 
Have we treated any other family members? 
Have your child's tonsils or adenoids been removed? 
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? 
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply): 
Does your child have speech problems? 
Does your child currently or has your child ever had any of the following habits (check all that apply): 

Medical History

Is your child currently being treated by a physician?
Do you have any allergies/sensitivities to foods, medications, or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

Authorization

I authorize the dentist to perform diagnostic procedures (exam, x-rays, cleaning) and treatment as necessary for proper dental care. I understand that responsibility for full payment of services is mine, and is expected when services are rendered, unless other arrangements have been made in advance. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I hereby authorize payment of insurance benefits directly to the dentist, otherwise payable to me.

I understand there will be a $30.00 charge for all returned checks, in addition to my account becoming a cash only account. I understand there may be a $100.00 collection fee for any balance turned over to an outside collection agency. I understand that there will be a fee charged for missed appointments.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information 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 understand that where appropriate, credit bureau reports may be obtained.

 

 


Security Measure

Double-T-Smiles Pediatric Dentistry and Orthodontics

  • Double-T-Smiles Pediatric Dentistry and Orthodontics - 6102 82nd St., Suite 2, Lubbock, TX 79424 Phone: 806-792-2288 Fax: 806-792-2768

2019  © All Rights Reserved | Website Design By: WestLogin