10021 Pines Boulevard, Suite 100 Pembroke Pines, FL 33024 18503 Pines Boulevard, Suite 304 Pembroke Pines, FL 33029 Phone: 954.417.4133 Fax: 954.417.1338 Web: www.americanpediatricdental.com OFFICE POLICIES AND PHILOSOPHY PARENTS/LEGAL GUARDIANS: Parent (or legal guardian with court papers) must be present for each visit and during the entire length of the visit. To send someone else with your child you must fill out and notarize the treatment decision assignment form OFFICE PHILOSOPHY- PLEASE READ CAREFULLY As part of our office philosophy, it is very important to spend as much time as necessary with each patient to fully address your dental problems. This enables our clinical staff time to explain dental treatment recommendations in depth and answer any questions you may have during your visit. Our staff schedules patients accordingly and we try to be as efficient as possible in order to expedite your entrance and departure from this office. Please be reassured that we value your time. However, given the unpredictable nature of our work, it is not uncommon to have a prolonged waiting period. Our office treats infants, children, children with special needs and medical conditions, and teens. On many occasions, we are delayed for such matters as patient s behavior, medical problems which require immediate attention and/ or emergencies. These issues are unforeseen and need to be addressed appropriately. We do not leave this office until all patients are seen and all their dental concerns are addressed. LATENESS/CANCELLATION/RESCHEDULING: We reserve the right to reschedule patients if they are not on time for their appointment if you are running late please call us. Please give us 24 hours advanced notice to cancel or reschedule your appointment. We enforce a strict two strike cancel/fail policy. Any patient who cancels in less than 24 hours from their appointment time or misses an appointment (in any combination) will be dismissed as a patient from our office after the second offense. Please keep your contact information current with us. In case of an emergency we may need to reschedule your appointment. CONTACT INFORMATION Our office uses phone, text messages, and emails to contact our patients. It is your responsibility to make sure all information is up to date every visit so we may contact you for future appointments or office emergencies. LIMITED SEATING POLICY Due to limited seating in the hygiene rooms, no more than 2 people accompanying the child will be permitted in the room. Please be mindful when making your appointment. Saturday appointments: Please note this is one of the busiest days of our office and limited seating is available in the waiting room. Please make appropriate accommodations for your family. Restorative appointments: Only 1 Parent is allowed in the room when treatment is being performed on the child Sedation appointments: NO parents or family members are allowed in the room while treatment is being performed for safety reasons. Parents can sit outside treatment room and watch the child. MULTIPLE INSURANCE: Patients with a Medicaid plan PLUS an HMO or PPO plan are not accepted, we are not equipped to bill multiple insurances. I ACKNOWLEDGE AND UNDERSTOOD THE ABOVE-STATED OFFICE POLICIES AND PHILOSPHY Name: Signature: Date:
EAST PINES 10021 Pines Blvd., Suite 100 Pembroke Pines, FL 33024 WEST PINES 18503 Pines Blvd., Suite 304 Pembroke Pines, FL 33029 954.417.1337 NEW PATIENT REGISTRATION FORM PATIENT (CHILD S) INFORMATION: Patient (Child s) Name: Date of Birth: Social Security #: Gender: Male Female Age: School Name: Reason for Today s Visit: Child s Pediatrician: Phone: RESPONSIBLE PARTY (PARENT OR LEGAL GUARDIAN) INFORMATION: Parent/Guardian Name: Date of Birth: Relationship to the patient? Biological Mother Biological Father Legal Guardian/Other: Street Address: City: State: Zip: Home Phone: Work Phone: Driver s License#: Cell Phone: Email: S.S.# Spouse Name: Date of Birth: Relationship to the patient? Biological Mother Biological Father Legal Guardian/Other: Street Address: City: State: Zip: Home Phone: Work Phone: Driver s License#: Cell Phone: Email: S.S.# How would you like us to contact you? E-mail Text Message Home Phone Cell Phone Work Phone EMERGENCY CONTACT: In the event of an emergency, whom should we contact besides you? Name: Relationship: Phone: Page 1 of 5
PLEASE CHECK ONE OF THE FOLLOWING REFERRAL SOURCES How did you hear about us? Insurance Provider List Naidu Orthodontics Joe DiMaggio Children s Hospital Google/Internet Search Sports and Activities Weston Sports and Activities Pembroke Pines Our City Pembroke Pines Davie Town Times Autism Notebook Cinemark/Regal Movie Theatres Nova Southeastern University Franklin Charter School Montessori Pembroke Pines Pines Charter School System Yellow Pages Yelp Facebook Twitter IF REFERRAL SOURCE IS LISTED BELOW PLEASE BE AS SPECIFIC AS POSSIBLE SO OUR OFFICE MAY PROPERLY THANK THE COMMUNITY FOR REFERRING US TO YOU! Word of Mouth / Friend (existing patient s name) Pediatrician (name of pediatrician if not listed below) Dr. Jacinth Brillante Dr. Hans Hubsch Dr. Carlos Patino Dr. Mario Zambrano Dolphin Pediatrics Pembroke Pines East Chapel Trail Cooper City Pediatric Associates location: Other Pediatric Associates location: General Dentist/Another Pediatric Dentist (name of dentist) Dental Provider in Our Office Dr. William Peña Dr. Lizette Valiente Event or Booth at Event Kids Konnection Snow Fest Other event Other Referral Source Page 2 of 5
MEDICAL HISTORY NONE OF THE BELOW APPLY Does your child have a history of any of the following? (Please check all that apply): Heart Murmur Seizures/Epilepsy Asthma Autism Heart Disease Cerebral Palsy Sleep Apnea ADHD Sickle Cell Disease Spina Bifida Tuberculosis Psychiatric Problems Organ Transplant Down s Syndrome Cancer/Tumors Eating Disorders Bone Marrow Transplant Diabetes Liver/Kidney Disease Drug/Alcohol Problems AIDS/HIV+ Speech/Hearing Issues GI Reflux Disease Developmental Delays Hemophilia/Thalassemia Recurrent Ear Infections Cystic Fibrosis Mental Retardation Blood Transfusions/Dialysis Abnormal bleeding Visual/hearing impaired Rheumatic Fever Other Elaborate on checked items: Optional: Race: Does your child have any allergies to the following? Language: NO KNOWN ALLERGIES Latex Penicillin Medications: Food/Other: Does your child take any medications? NO MEDICATIONS TAKEN Yes, please list: Has your child ever been hospitalized or had surgeries? NEVER BEEN HOSPITALIZED Yes, please specify: DENTAL HISTORY Is this your child s first visit to a dentist? Yes NO, my child was at a dentist on the following date: How many times per day does your child BRUSH his/her teeth? 0 1 2 3 Adult Supervision? Yes No How many times per day does your child FLOSS his/her teeth? 0 1 2 3 Adult Supervision? Yes No Has your child ever had any trauma or injuries to the mouth or teeth? NO PAST TRAUMA/INJURIES Yes, please specify: Does your child currently have any dental pain? NO DENTAL PAIN Yes, please specify: Has your child had dental pain/infection in the past? NO PAST PAIN/INFECTION Yes, please specify: Does your child have any of the following habits? Thumb/Finger Sucking Lip Biting/Sucking Mouth Breathing Nail Biting Teeth Grinding/Clenching Pacifier Use Snores while sleeping Protrudes Tongue Does your child fall asleep with the bottle or sippy cup in his/her mouth? NONE OF THE BELOW APPLY NO BOTTLE/SIPPY CUP WHEN SLEEPING Yes, please specify: Page 3 of 5
INSURANCE INFORMATION: NOTE: WE DO NOT BILL MULTIPLE INSURANCES Do you have insurance coverage for your child? Yes No I have already provided you with this information (if so, please read below, sign and date and move on to the next page) Policy Owner Name: Date of Birth: Insurance Company: Policy #: Group#: Insurance Company Address: City: State: Zip: Insurance Company Telephone: FOR PATIENTS WITH DENTAL INSURANCE: I understand that the uses all resources available to them to verify my insurance however those resources do no provide a guarantee of payment. All claim payments are determined at the time of claim submission. Furthermore I certify that my child is covered by the above named insurance company and I assign directly to the all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature and all my insurance submissions, whether manual or electronic. Should the account be referred to any attorney for collection, the undersigned shall pay reasonable attorney s fees and expenses. PLEASE NOTE: Payment in full is expected at the time of dental treatment. The parent or guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been made. Since we reserve a special time to offer quality treatment for your child, patients with two or more broken or cancelled appointments without a minimum 24 hour notice will result in discontinuation of any further dental services, except for 30 days of dental emergencies. I affirm that all the information that I have given in these 5 pages is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this 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. SIGNATURE OF PARENT OR GUARDIAN DATE Page 4 of 5
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES VERY IMPORTANT: YOU MUST COMPLETELY READ THE APDG HIPPA NOTICE OF PRIVACY PRACTICES BEFORE SIGNING THIS ACKNOWLEDGEMENT FORM! I have legal authority for this child and acknowledge that I have received AND reviewed my copy of 's HIPAA Notice of Privacy Practices. Print Name of Parent or Legal Guardian (if you are the parent print, sign and date here only) Parent/Legal Guardian s Signature Date If you are the personal representative please state your relationship to the patient that gives you authority over him/her: Power of Attorney Other: OR Print Name of Personal Representative Personal Representative s Signature Date Please Note: It is your right to refuse to sign this Acknowledgement. ******Dental Office Use Only****** I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: An emergency prevented us from obtaining acknowledgement. A communication barrier prevented us from obtaining acknowledgement. The individual was unwilling to sign. Other: Print Name of Staff Member Staff Member s Signature Date Page 5 of 5