New Patient Paperwork

Child Details

Child's full name

Date of birth

School child attends

Male

Female

Grade

Home address

Home phone number

City

State

Zip code

Family dentist

Child's last visit

Other family members who are patients here

How did you hear about us

Reason for today's visit

Person accompanying patient to our office today & relationship

Please check preferred form of communication:

Phone call

Text message

Either

Mother Details

Name

Social security number

Date of birth

Home address

City

State

Zip code

Occupation

Home phone number

Cell phone number

Employer

Business telephone number

Father Details

Name

Social security number

Date of birth

Home address

City

State

Zip code

Occupation

Home phone number

Cell phone number

Employer

Business telephone number

Subscriber Information

Subscriber name

Date of birth

Employer

Submitting address

Name of insurance company

Group number

SSN or Member Id

Permission For Treatment and Payment Policy

PERMISSION FOR DENTAL TREATMENT

I give my permission to Dr. Gonzalo Hernandez, DDS,and/or Dr. Alexandra Wetzel,DDS to perform all necessary procedures. Dental Haven requests a parent or guardian present for all appointments for children under the age of 18. I understand that if I am not present at my child’s appointment, this may limit what treatment is performed at the appointment. In the event my child needs treatment, Dr. Gonzo, Dr. Alexandra, and/or staff will inform of the different types of methods of restorative treatment. I understand there is no guarantee of success or permanence to the treatment. If I have any questions regarding treatment, procedures, or insurance, it is my responsibility to make sure my questions have been answered by Dental Haven or my insurance company prior to signing the proposed treatment plan consent form. I, therefore, understand the above statement and consent to the use of procedures if deemed necessary by Dr. Gonzo or Dr. Alexandra.

The parent or guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.

PAYMENT POLICY
INSURANCE:

In most cases, insurance does not cover the full cost of services. It is designed to reduce your cost, but not to eliminate it completely. Our staff will help you receive the maximum benefit available under your policy. However, please remember you are fully responsible for all fees charged by this office regardless of insurance coverage.

We submit all claims to your insurance company after each appointment. The balance that is not covered by insurance is due on the date of service. The following methods of payment are available:

**Cash or check

**Visa/Mastercard

**American Express

**Discover

**CareCredit

Should you need copies of dental records, there is a $4.00 processing fee for technician time, materials, and postage. If ortho models need to be copied, the fee is $55.00.

Any cancellation without giving 24 hours notice or failure to keep the appointment will result in a charge of $55.00.

I have read and hereby agree that I am ultimately responsible for payment of this account.

Child Details

Child's full name

Birth date

Age

Male

Female

Medical physician

Medical physician phone number

Date of last medical exam ?

Height(feet)

Weight(lbs)

Details

Check for Yes

Problems

Details

Has your child ever been hospitalized, had general anesthesia, or emergency room visits?

Is your child up to date on all recommended immunizations for their age?

Is your child in good health at this time?

Is your child experiencing any pain or discomfort at this time?

Does your child have a latex allergy?

Does your child have any anxiety about seeing the dentist?

Developmental History

Please check the following if your child is the age of 0-3 years old

Check for Yes

Problems

Details

Baby born premature

Problem during pregnancy

Problems immediately after birth?

Rh or blood disorder?

Feeding problems?

Did baby go home from hospital with mother?

PLEASE COMPLETE FOR ALL CHILDREN

Questions

Age

At what age did your child stand?

At what age did your child walk?

At what age did your child talk?

Check for Yes

Problems

Details

Was your child breast fed? When stopped?

Was your child bottle fed? When stopped?

Did your child use a pacifier? When stopped?

Has your child ever sucked a finger or thumb? When stopped?

Has your child ever chewed lips or fingernails? When stopped?

Is your child adopted?

Please complete the following if your child is the age of (9‐18 years ofage)

Check for Yes

Questions

Has your child recently had a growth spurt?

Do you think your child has stopped growing?

Has your child shown any signs of reaching puberty?
(Example: Girls‐monthly menstruation,Boys-Shaving,voicechange)

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain 
rights to privacy regarding my protected health information. I understand that this information may be used for:

                                                                                                                                                                                                                                     
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use or disclose your health information to obtain payment for services provided.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. 
Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, 
evaluating practitioner and provider performance, conducting training programs,accreditation, certification, licensing or credentialing activities.
 
Your authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written 
authorization to use your health information or disclose it to anyone for any purpose.If you give us an authorization, you may revoke it in 
writing at any time. Your revocation will not affect use or disclosures permitted by your authorization while it was in effect. 
Unless you give us written authorization,we cannot use or disclose your health information for any reason except those described in this Notice. 
To Your Family & Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice.We may 
disclose your health information to a family member, friend or other person to the extent necessary to healthcare or with payment for your 
healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in notification of (including identifying or locating) a 
family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If
you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or
disclosures.In the event of your incapacity or in emergency circumstances, we will disclose your health information based on a determination 
using our professional judgment,disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We 
will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in 
allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of
abuse,neglect or domestic violence or the possible victims of other crimes. We may disclose your health information to the extent necessary to 
avert a serious threat to your health or safety or the health or safety of others.
National Security: Under certain circumstances, we may disclose to military authorities the health information of Armed Forces personnel. We 
may disclose to authorized federal officials any health information required for lawful intelligence, counterintelligence, and other national 
security activities.We may disclose to correctional institutions or law enforcement officials having lawful, custody protected health information
of inmates or patients under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail
messages, postcards or letters).

________________________________________________________________________________________________________________________________________
Your signature below indicates that to the best of your knowledge, all information entered in the patient registration and medical history 
portion of this document is accurate and up to date.Your signature below indicates that you agree to our dental treatment and payment policies.
Furthermore, your signature below indicates that you understand Dental Haven’s compliance with the federal HIPAA laws.
If you’d like a full copy of HIPAA, please ask a member of the Dental Haven Staff.
________________________________________________________________________________________________________________________________________

Patient Name:

Parent or Legal Guardian Name:

Signature: