Our office is committed to meeting or exceeding the standards of infection controt mandated by OSHA, the CDC and the ADA, 4 19 ou ace. our goa Price eM based on preventive ol ane 2 aot RO ailing! gas Social Security #. Name Last First Initial] Relationship to chil Nickname: Your home phone and address if different Birthdate: 5 Male || Female Month Day Year from childs: Home Phone “aires Special interests or hobbies: Heo ‘Occupation: — Home Address; Employer: __ Bgl tg Home Phone: Cell phone: Email Referred by: — | con accept oppoiniment confirmations by: Phone Text Email Cie al that app. DENTAL INSURANCE COMPANY #1 : DENTAL INSURANCE COMPANY #2 Dental Ins, Co: Dental Ins. Co: Address: Address: ___ — — Their phone #: ——_— ———— } Their phone #; ———_________ Group # —— } Group #: a This Dental Insurance is provided through: This Dental Insurance is provided through: Their name: — Their name; Relationship to child: __________} Relationship to child — Their Social Security #:_ ‘Their Social Security # ‘Their birthdate: - ‘Their birthdate: ‘Their employer: : Their employers ——————_______DENTAL/MEDICAL HISTORY Has your child been to the dentist before? © Yes [No Has your child ever had any of the following medical conditions or problems? If yes, the approximate date of last visi: ____| ‘Are there any dental problems that you are aware of at present? © Yes ©) No If yes, please expla Please circle YN Heart Murmur YN Heart problems of any kind Does your child brush his/her teeth daily? 2 Yes <1 No YN Convulsion/Epilepsy YN Cancer Please rate your childs oral health. “Good = Fair C) Poor Is your child currently under the care of a physician? © Yes © No YN Diabetes YN Rheumatic Fever YN HIV+AIDS Chile's physician: ‘Their phone #: YN Hemophilia YN Bleeding problems of any kind ‘The approximate date of last visi: Please rate your child's medical health, C Good © Fair © Poor YN Hearing Impairment Is your child allergic to any drugst CYes 0.No bid sahae 7 YN Hyperactive YN Any Operations yes, please list: YN Any stays in hospital YN Asthma |s your child taking any prescription drugs? © Yes CI No If yes, please list: ‘Are there any other medical conditions or problems CYes Ne relating to your child? 3 Yes C No Does your child need to be premedicated before dental treatment? If yes, please list: Relationship: Phone #2: understand that the Information that | have given 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 also authorize the dental staff to perform the necessary dental services my child may need. The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved. ONSET FOR EXAMINATION AND DIAGNOSTIC X-RAYS OFX MINOR 1 at a atte ol aie ed ee ge gp i i 1 Bee pata = pub i ry ea Boal le hss oe lB 1 nad et ed pl ey eel yb Spe pps he fll ge of rec Pea a (Soe he mg alo yt ay ne ar ee de eg nw i Signature of parent or guandian teG BY ic Dentistry & Orthodontics NOTICE OF PRIVACY PRACTICES ‘THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE-USED AND DISCLOSED ‘AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. => THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. ‘OUR LEGAL DUTY ‘We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We ‘must follow the privacy practices that are described In this Notice while Its In effect. This Notioe takes effect 04/14/03 and will remain in effect until we replace it. ‘We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our "Notice effective for all health information that we maintain, including health information we created or received before we ‘made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the ‘new Notice available upon request. ‘You may request a copy of our Notice at any time, For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION ‘We use and disclose health information about you for treatment, payment, and healthcare operations. For example: ‘Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment toyou. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healtheare operations. Healthcare operations include quality assessment and improvement acthitie, reviewing the competence or qualifications of hhealthoare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, oar- {ification, licensing or credentialing activities. Your Authorlzation: In addition to our use of your health information for treatment, payment or healthcare operations, you ‘may give us writen authorization to use your health information or to 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 any use or disclosures permitted by your authorization while ft was in effect. Unless you give us a written authorization, we cannot use or disclose your health infor- ‘mation for any reason except those dosoribed in this Notice. To Your Family and 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, tdend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only f you agree that we may do so. Persons involved in Care: We may use or disclose health information to notify, or assist in the notification of (noluding iden- tifying or locating), a family member, your personal representative or another porson responsible for your care, of your loca ‘on, your general condition, or death, f you are present, then prior to use or disclosure of your health information, we wil brovide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circum- ‘stances, wo will disclose health information based on a determination using our professional judgmont, disclosing only health Information thet is directly relevant to the person's involvement in your healthoare. We will also use our professional judg- ‘ment and our experience with common practice to make reasonable inferences of your best interest In allowing a person to pick up filed prescrintions. medical supplies. x-ravs. or other similar forms of hesith Information."ak SIM Pediatric Dentistry & Orthodontics ‘Marketing Health-Related Services: Wo will not use your heaith information for marketing communications without your vtit- ten authorization, 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 ‘ possible victim of abuse, neglect, or domestic violence or the possible victim 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: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful inteligence, counter- Inteligence, and other national security activities. We may disclose to correctional institution or law enforcement officials hav- Ing lawful custody of 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 ‘8 voloemeil messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that ‘we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do ‘so. You must make a request in writing to obtain access to your health information. You may also request access by sending Usa letterto the address at the end of this Notice. We reserve the right to charge you a reasonable cost-based fee for expens- ‘es such as copies and staff timo, Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed ‘your health information for purposes other than treatment, payment, healthcare operations and certain other activites, fr the last 6 years, but not before April 14, 2003 If you request tis accounting more than onoo in a 2-month period, we may charge ‘you a reasonable, cost-based fee for reeponding to these additonal requecte. ‘Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your heath infor- ‘mation. We are not required to agree to these additional restictions, but if we do, we will abide by our agreement (except in ‘an emergency). ‘Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing Your request must specify the alterna tive means or location, and provide satistactory explanation of how payments wll be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your heath information. (Your request must be in writing, and it ‘must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: It you receive this Notice on our Wob site or by electronic mall (e-mail), you are entitled to receive this Notice in vrition form,eee Sim) Pediatric Dentistry & Orthodontics ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES “You may refuse to sign this Acknowledgement” L, have received a copy of this office's Notoe of Privacy Practices. Please Pat Name For Office Use Only ‘We attempted to obtain written acknowiedgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refed to sign CCommanicatios barr prokbited obtaining acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (leas specify)Z Sim GF a Dentistry & Orthadontics Dental Office Behavior Management Technique The following information is provided to allow you to make informed personal decisions concerning your childs dental ‘treatment after considering the risks, benefits and alternatives. Please read this carefully and ask about anything you do not understand. . itis important that you appreciate that our phlesophy isto treat our patients the same way we want our own children to be treated. iis our intent that all dental cae here be of he best possible qualty we can provide for your child, This can be challenging due tothe lack of ablit to cooperate that we experience in a few of our patients. Behaviors that can interfere wth ‘he proper provision of dental treatment are: hyperactivity, resistive movements, refusal to open mouth or keep it open, biting and physical resistance to treatment such as Kicking, sereaming, and grabbing the dentist's hands or sherp instruments. Our {goa sto help our patients master the dental experience gently and safely Al efforts are made to obtain the cooperation of ‘ur patents by use of warmih,fiendiness, persuasion, humor, charm, kindness and understanding ‘There are several recognized management techniques that are used by pediatic dentists to gain the cooperation of young Patients, o eliminate disruptive behavior or prevent patents from causing injury to themselves due to uncontrollable ‘movements. We combine the following recognized techniques individually for each child inthe least restrictive environment possible, * TELL-SHOW-DO: The child is told what is to be done using simple words and then shown on a finger. Then the procedure is done exactly as told. Praise is given to reinforce all positive behavior. Children have less ‘anxiety when they know what to expect. ‘+ VOICE CONTROL: The attention of a child exhibiting disruptive behavior is gained by changing the tone or volume of the dentists voice. Content of the conversation is less important than the abrupt or sudden nature of the voice change. A raised voice does not indicate anger at your child. * MOUTH REST: A device placed in the patient's mouth to prevent accidental closing and/or injury and to allow jaw muscles to relax for ease of swallowing. It can be as simple as a toothbrush handle, * PHYSICAL RESTRAINT BY DENTISTIASSISTANTS: The restraining of the child from undesirable movement by stabilizing the child's head, holding the child's hands and or! controling leg movements with the intention of preventing possibie injury. (You probably do this when your child needs a splinter removed.) ‘* DAY SURGERY: An option to perform dental services under a general anesthetic in the hospital. We do this as a last resort and prefer to care for your child's teeth in our office whenever possible, | hereby authorize and direct the dental staff at Dr. Keal's Office to utlize the behavior management techniques listed above to assist the provision of the necessary dental treatment with the exception of If none, state so). | hereby acknowledge that | have read and understand this consent, Patient's Name: ‘Signature of Parent or Guardion: Office Representative's Signature:my Simply Pediatric Dentistry & Orthodontics OFFICE POLICIES PAYMENTS: Payment is expected on the date of treatment. Insurance: As a courtesy we will submit charges for treatment to your insurance company. We also will submit a pre-treatment estimate to give you a more accurate idea of your coverage. You are expected to satisfy your co payments and any deductibles on the date services are rendered. You must have a valid insurance card in order to submit claims, should you not have one you will be responsible for the entire amount at the time of the appointment. ‘We will assist you with understanding your insurance coverage. Please be advised that insurance companies change constantly and that you need to be responsible for knowing your own insurance coverage. APPOINTMENTS: We ask that you please give us 24 hour notice if you are unable to keep your dental appointment. We can successfully offer these appointments to other patients who are waiting if we give them sufficient time. WE NEED A VERBAL CONFIRMATION THAT YOU WILL BE ARRIVING FOR ALL DENTAL APPOINTMENTS. We confirm the appointments for you as a courtesy. If we leave a message you need to call us back to verbally confirm you will be arriving for the scheduled appointment. Ihave read and understand the office policies as listed above. Signature: Date: 76 Allds Street 603-880-5002 Nashua, NH 03060 www.simplypedoortho.comCF: Bede Dentistry & Orthodontics Non — Parental Consent to Dental Trea L, parent/legal guardian of the child/children listed below do hereby give authorization and consent for the authorized person(s) reflected below to consent to authorize the dental services provided to my child/children. I hereby authorize and grant the below named person(s) has/have permission from the parents/legal guardian for any dental care and treatment deemed necessary for the well being of my child/children. Iam, by this document, representing that I have authority to consent for all dental care and treatment of said child/children: Child/children Name Name Name. Name Authorized person(s): Name ’ Relationship to parent/Guardian Name Relationship to Parent/Guardian Signature of Parent/Legal Guardian Date IDENTIFICATION MUST BE ON FILE FOR AUTHORIZED PERSON(S)