1-877-489-8338
[email protected]
texasdentistryforkids.com/texasdentistry.com
Medical Alert for Office Use
Thank you for visiting TDFK. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Patient Information
Legal Name: LAST ________________________ FIRST ___________________________ MIDDLE_______________________
Preferred Name: _______________________ Mother’s Maiden Name: ____________________________ Sex: □ Male □Female
DOB: _____/______/_____ Social Security #:_____-_____-______ Language Preferred: □ English □ Spanish □ other: ______________
Address: _______________________________________________City/State/ Zip: _____________________________________________
Cell Phone: ________________________ Alternate Phone: ___________________________Home Phone: ________________________
Email: __________________________________________________ Would you like to be updated by text message/email? __Yes __No
May we know how you heard about our office? ________________________________________________
Parent/Responsible Party Information
**DIVORCED PARENTS: It is the policy of this office that the parent accompanying the child for the appointment will be held
responsible for all charges regardless of the insurance or financial responsibility. Texas Dentistry for Kids will not bill or discuss treatment
with the other parent.
Are parents married? Yes No If no, which parent does patient usually live with? ___________________________________________
Mother’s Name or Legal Guardian: ___________________________ D.O.B ____/____/____ Relation to Patient: __________________
SS# ________________________Address: __________________________________________ City/State/ Zip: ______________________
Cell Phone: _______________________ Home Phone: ___________________________Alternate Phone: ___________________________
Employer Name: _____________________________ Address: ____________________________ City/State/Zip: _____________________
Father’s Name or Legal Guardian: ____________________________ D.O.B ____/____/____ Relation to Patient: __________________
SS# ________________________Address: __________________________________________ City/State/ Zip: ______________________
Cell Phone: _______________________ Home Phone: ___________________________Alternate Phone: ___________________________
Employer Name: _____________________________ Address: ____________________________ City/State/Zip: _____________________
Consent for Minor – UNDER 18 YEARS OF AGE
**The individuals listed are the only ones that can bring the patient to any cleaning and/or treatment appointment. If the patient needs to have
treatment performed with Non IV Sedation, ONLY the parent/legal guardian can bring the patient to the treatment appointment and sign off
on pre operative paperwork.
Patient's Name: _________________________________________
Are you the:
● Parent (please write your name and your spouse’s name) _________________________________________________
● Legal Guardian (please write your name) _____________________________________________________________
● Other (please write your name and explain why) ________________________________________________________
If we cannot reach you about the changes in the child's treatment, are there others that you would allow to give consent in your
absence? (must be over 18) If YES, please give the names and relationship to the patient.
_______________________________________________________________________________________________________
List the individuals that you give permission to receive treatment and payment
information:_____________________________________________________________________________________________
Please list anyone that you would not allow to consent in your absence. _____________________________________________
Signature: _______________________________________
Date/Time: ___________________________________________
Texas Dentistry for Kids
Page 2 of 7
Emergency Contact Information (Not in same household)
Name: ________________________
Relationship to Patient:__________________ Contact Phone Number:______________________
Insurance Information
Primary Insurance: __________________ Eligibility/Benefits Ph #:____________________ SS#/Policy #: _______________________
Subscriber/Cardholder: ________________________DOB:________________Address:________________________________________
Secondary Insurance: __________________ Eligibility/Benefits Ph #:___________________SS#/Policy #: _______________________
Subscriber/Cardholder: ________________________DOB:________________Address:________________________________________
Physician Information
Primary Care Physician _____________________________________________ Phone #: _______________________________________
Address: ___________________________________ City/State/ Zip: ______________________________Fax Phone:_________________
Specialty Physician Name: ___________________________________________ Phone #: _______________________________________
Address: _________________________________ City/State/ Zip: ______________________________ Fax Phone: __________________
Insurance Authorization Statement
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I
understand that I am responsible for all costs and dental treatment. I also understand that it is my responsibility to
give accurate insurance information to the best of my knowledge. I hereby authorize the Dental Office to administer
such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care.
The information on this page and the medical history is correct to the best of my knowledge.
Signature: ____________________________________________
Date/Time: ______________________________________________
Chief Complaint
Motivo principal de la consulta
Reason for today’s visit:____________________________
_______________________________________________
What would you like to talk about or have happen today?
_______________________________________________
Motivo de la consulta:_____________________________
_______________________________________________
De que desea hablar o que necesita hoy?_______________
_______________________________________________
Past History
Antecedentes
Are immunizations UP TO DATE?
□No □Yes
Is the patient allergic to any medications?
□No □Yes
If yes, please list:________________________________
Please list reactions:_____________________________
Is the patient allergic to LATEX?
□No □Yes
Is the patient taking prescribed medications?
□No □Yes
Medications
Dose
Times Per Day
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Estan sus vacunas AL DIA?
□No □Si
Es el paciente alergico a algun medicamento? □No □Si
Si la repuesta es si, por favor indique a cuales:___________
Por favor, especifique la reaccion:_____________________
Es el paciente alergico al LATEX?
□No □Si
Toma el paciente medicamentos recetados?
□No □Si
Medicamentos
Dosis
Cuantas veces al dia
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Texas Dentistry for Kids
Page 3 of 7
Past History
Antecedentes
What was the patient’s birth weight? ____pounds __ounces
Was the patient premature?
□No □Yes
Did the patient have breathing problems?
□No □Yes
Did the patient have jaundice?
□No □Yes
Did the patient have blood transfusions?
□No □Yes
Did the patient stay in the newborn ICU?
□No □Yes
Did the patient have complications during birth? □No □Yes
If yes, please explain:______________________________
_________________________________________________
Has the patient ever been hospitalized?
□No □Yes
If yes, please list reason/when:_______________________
_________________________________________________
Has the patient had any operations?
□No □Yes
If yes, please list what/when:________________________
_________________________________________________
Cual fue el peso del paciente al nacer? ____libras ____onzas
Tuvo el paciente un nacimiento prematuro?
□No □Si
Ha padecido el paciente problemas respiratorios?□No □Si
Ha tenido el paciente icteria (color amarillento)? □No □Si
Se le han hecho al paciente transfusiones de sangre? □No □Si
Estuvo el paciente en terapia intensiva (ICU) al nacer? □No □Si
Presento el paciente complicaciones durante el nacimiento?
Si la repuesta es si, por favor explique:__________________
__________________________________________________
Ha sido el paciente alguna vez hospitalizado?
Si la repuesta es si, por favor indique el motive y cuando
ocurrio:____________________________________________
Se ha sometido al paciente a alguna operación?
Si la repuesta es si, por favor indique que tipo y cuando
ocurrio:____________________________________________
Has the patient had any serious illnesses of the following?
Asthma
Autism
ADD/ADHD
Sleep Apnea
Seasonal/Environmental Allergies
Autoimmune Disorders
Bleeding Disorders
Births Defects
Brain Damage or Neurologic Problems
Developmental Problems
Diabetes
Hypoglycemia-Low Blood Sugar
Heart Disease or Heart Murmur
Tuberculosis
Rheumatic Fever
Seizures or Convulsions
Sickle cell Disease or Trait
Cancer/ Malignant Tumor
Radiation?
Chemotherapy?
Currently pregnant?
Trimester: (please circle) 1st 2nd 3rd
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
Ha padecido el paciente alguna de las siguientes enfermedades?
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
Has the patient had any or ever been exposed to the following:
Hepatitis
□No □Had □Exposed to
Date______
Herpes
□No □Had □Exposed to
Date______
HIV/AIDS □No □Had □Exposed to Date______
Scarlet Fever □No □Had □Exposed to
Date______
Asma
Autismo
ADD/ADHD
Apnea del sueño
Alergias de temporada/ ambienales
Trastornos autoinmunitarios
Trastornos hemorragicos
Defectos congenitos
Dano cerebral o problemas neurologicas
Problemas de desarrollo
Diabetes
Hipoglucemia
Enfermedad o soplo cardiaco
Tuberculosis
Fiebre reumatica
Convulsiones o epilepsia
Anemia drepanocitica o rasgo
Cancer/ Tumor malign
Radiacion?
Quimioterapia?
Actualmente esta embarazada?
Trimestre: (please circle) 1st 2nd 3rd
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
□Si
Ha padecido el paciente o alguna vez ha estado expuesto a alguno de los siguientes?
Hepatitis
Herpes
VIH/sida
Escarlatina
□No
□No
□No
□No
□Had
□Had
□Had
□Had
□Exposed to
□Exposed to
□Exposed to
□Exposed to
Fecha______
Fecha______
Fecha______
Fecha______
Review of Systems
Has the patient had any of the following problems? If yes
Please describe
Dizziness / Fainting Spells
□No □Yes __________
Eye Problems
□No □Yes __________
Headaches
□No □Yes __________
Ear infections
□No □Yes __________
Nose Bleeds
□No □Yes __________
Sleep Apnea
□No □Yes __________
Sore Throat
□No □Yes __________
Runny Nose
□No □Yes __________
Breathing Problems
□No □Yes __________
Pneumonia
□No □Yes __________
Teeth/ Sore Gums
□No □Yes __________
Stomach Problems
□No □Yes __________
Kidney /Bladder Problems
□No □Yes __________
Sore Joints
□No □Yes __________
Muscle Weakness
□No □Yes __________
Genetic Disorders
□No □Yes __________
Endocrine /Hormone Problems □No □Yes __________
Family History
Do any family members have any medical problems? If yes,
Please list which family member
Bleeding Disorder
□No □Yes __________
Asthma
□No □Yes __________
Birth Defects
□No □Yes __________
Diabetes
□No □Yes __________
Hypoglycemia
□No □Yes __________
Neuromuscular Problems
□No □Yes __________
Sickle Cell Disease
□No □Yes __________
Seizures or Convulsions
□No □Yes __________
Trouble with Anesthesia
□No □Yes __________
Malignant Hyperthermia
□No □Yes __________
Examen de los sistemas corporals
Ha presentado el paciente alguno de los siguientes problemas?
Si la respuesta es si, por favor especifique :
Mareos / Desmayos
□No □Si _____________
Problemas de la vista
□No □Si _____________
Dolores de cabeza
□No □Si _____________
Infecciones de oido (otitis)
□No □Si _____________
Hemorragia nasal
□No □Si _____________
Apnea del sueno
□No □Si _____________
Dolor de garganta
□No □Si _____________
Nariz aguada
□No □Si _____________
Problemas respiratorios
□No □Si _____________
Neumonia
□No □Si _____________
Dolor de dientes o encias
□No □Si _____________
Problemas estomacales
□No □Si _____________
Problemas renales o de vejiga □No □Si _____________
Articulaciones adoloridas
□No □Si _____________
Debilidad muscular
□No □Si _____________
Trastornos geneticos
□No □Si _____________
Problemas endocrinos u hormonales□No □Si _____________
Antecedentes famillares
Alguno de sus familiars tiene algun problema medico? Si la
respuesta es si, por favor indique que familiar.
Trastornos hemorragicos
□No □Si _____________
Asma
□No □Si _____________
Defectos congenitos
□No □Si _____________
Diabetes
□No □Si _____________
Hipoglucemia
□No □Si _____________
Problemas neuromusculares
□No □Si _____________
Anemia drepanocitica
□No □Si _____________
Convulsiones o epolepsia
□No □Si _____________
Problemas con la anestesia
□No □Si _____________
Hipertermia maligna
□No □Si _____________
Additional Information:
_______________________________________________________________________________________________________
Signatures
Firmas
Assistant Name:___________________________________
Assistant Signature:________________________________
Date:__________________ Time:_____________________
Parent/Legal Guardian Signature:______________________
Date:__________________ Time:_____________________
I have reviewed the above information.
Dr. Signature:_____________________________________
Date:__________________ Time:_____________________
Nombre del Asistente: _______________________________
Firma del Asistente: _________________________________
Fecha: ____________________ Hora: ___________________
Firma del padre o tutor lega: ___________________________
Fecha: ____________________ Hora: ___________________
He revisado la informacion que precede.
Firma del medico:___________________________________
Fecha:____________________ Hora: ___________________
Texas Dentistry for Kids and Oral Health Industries, LLC complies with applicable Federal civil rights law and does not discriminate on the
basis race, color, national origin, age, disability, or sex.
Texas Dentistry for Kids
Page 5 of 7
Consent/Consentimiento
Do you give consent for dental x-rays to be taken?
Da usted su consentimiento para radiografias dentales se deben tomar?
□No □Yes If No, Reason?___________
□No □Si Si No, La Razon?_____________
Do you give consent for prophylaxis cleaning to be performed?
Usted da consentimiento para proceder con la limpieza?
□No □Yes If No, Reason?___________
□No □Si Si No, La Razon?_____________
I GRANT/DO NOT GRANT permission for my photo/image, without any other personal identifiers, to be published on the
Texas Dentistry or any affiliated website.
Yo CONCEDO/ NO CONCEDO permiso para mi foto / imagen que no incluya ningún otro identificador personal, que se
publicara en la pagina de internet de Texas Dentistry.
PATIENT PRIVACY AND COMMUNICATIONS.
Texas Dentistry for Kids (TDFK) offers patients/guardians the opportunity to communicate with their dental office by
encrypted email or messaging. Encrypted email is a secure method of communication. Please make note of the
following risks of use of unencrypted email/ text messaging:
 Email/ text can be copied, circulated, forwarded, and stored in electronic files
 Email/ text, whether accidentally or intentionally, can be broadcast worldwide immediately and received by
many unintended recipients
 Email/ text is easier to falsify than handwritten or signed documents
 Backup copies of email/ text may exist even after the client has deleted his or her own copy
 Employers and online services may have a right to archive and inspect emails/ texts transmitted through their
systems
 Passwords providing access to email/ texts can be stolen and misused, or host systems can be compromised,
leading to unauthorized disclosure of personal information
 Email/ texts can be intercepted, altered, forwarded, or used without written authorization or detection
I hereby authorize TDFK to use unsecured email and mobile phone text messaging to transmit to me the
____ following protected health information: 1) Information related to the scheduling of appointments; and, 2)
Initial Information related to billing and payment.
____ I hereby authorize that TDFK may leave messages on my voicemail to confirm appointments, and/or may
Initial speak with other members of my household and leave messages with them regarding my appointments.
___ Email
___ Home Phone ___ Office Phone ___ Cell Phone
____ I hereby authorize that TDFK may disclose my health information to any person(s) who accompany me to
Initial my appointment, and are present with me in the office while I meet with my dentist and staff.
____ I hereby authorize that TDFK may disclose my personal health information to the person who I have listed
Initial as my emergency contact.
____
Initial I hereby authorize that TDFK may disclose my personal health information to the following person(s):
Name
Telephone Number
Relationship to Patient
Date: ________________ Signature: __________________________ Relationship to Child: ___________________
Texas Dentistry for Kids
Page 6 of 7
Notice of Privacy Act
This notice describes how medical and dental information about you and/or your child may be used and disclosed and how you can get
access to this information. Please review it carefully.
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses,
home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
1. To other health care providers (i.e., your/or your child’s oral surgeon,ect.) in connection with our dental treatment to you or your
child.
2. To third party payers or spouses (ie., insurance companies, employers with direct reimbursement, administrators of flexible
spending accounts, ect.) in order to obtain payment of your account (ie., to determine benefits, dates of payment, ect)
3. To certifying, licensing and accrediting bodies (ie., the American Board of Dentist, state dental boards, ect.) in connection with
obtaining certification, licensure or accreditation.
4. Internally, to all staff members who have any role in your/or your child’s treatment; and or,
5. To other patients and third parties who may see or over hear incidental disclosures about your/ or your child’s treatment, scheduling
ect:
6. To your family and close friends involved in your/ or your child’s treatment;
7. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits
and services that may be of interest to you;
And other uses or disclosures of you, or your child’s protected health information will be made only after obtaining your written
authorization, which you have the right to revoke.
Request restrictions on the use and disclosure of your/ or your child’s protected health information;
Request confidential communication of your, or your child’s protected health information;
Inspect and obtain copies of your, or your child’s protected health information through asking us;
Amend or modify your, or your child’s protected health information in certain circumstances;
Receive an accounting of certain disclosures made by us of your, or your protected health information; and,
You may, without risk of retaliation, file a complaint regarding a dental professional, by e-mailing the SBDE Enforcement Division
at [email protected] or by phone @1.800.821.3205 (which must be filed within 180 days of the violation)
We have the following duties under the privacy rules:
1. By law, to maintain the privacy of, protected health information and to provide you with this notice setting forth our legal duties and
privacy practices with respect to such information;
2. To abide by the terms of our Privacy Notice that is currently In effect;
3. To advise you of right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected
health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
1. Honor any request by you to restrict the use of disclosure of your protected health information:
2. Amend your protected health information if, for example, it is accurate and complete, or,
3. Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by
other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information on this Notice, please ask for
our Privacy Person or direct your questions to this person at our office address. Thank you.
1.
2.
3.
4.
5.
6.
PATIENT ACKNOWLEDGEMENT
I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice
________________________________________
Patient/Responsible Party
_________________________
Date
Page 5 of 7
Financial Agreement
Please read entire form carefully, then sign and date.
The following defines the financial policies of this practice.
Payment is due at the time of services are rendered
The administrative staff will estimate the amount you owe for procedures the doctor or hygienist has
completed or those procedures which are in progress. Please take into account that this is only an estimate.
The actual out-of-pocket expense may be less than or greater than the amount estimated and collected. You
may be billed for the difference or reimbursed. Some insurance plans require the patient to pay only a
percentage or co-payment directly to our office. Some plans require the patient to pay the entire amount
due for the visit.
Insurance Coverage
We accept many different insurance plans. All plans have a unique schedule of covered services
depending on what plan you or your employer have purchased. There is no guarantee that services will be
covered. You, or the person responsible for this account, will be responsible for payment of non-covered
procedure and/or denied procedures. There may be additional charges to cover the cost of parts or lab fees,
depending on the treatment provided and type of insurance coverage. If you wish, we can send a predetermination to your insurance carrier. The advantage of this is knowing approximately what your out-ofpocket expenses will be. There is a disadvantage due to treatment being delayed. This in itself could
complicate matters as problems may worsen.
Major Work
Patients receiving major work (crowns, bridges, dentures) or bleaching kits must have their portions
completely paid off before the work can be delivered or cemented. In the case of a waiting period being over
looked you will be responsible for the full charges as this counts as a non covered service. In the event of
your insurance having a missing tooth clause you will be responsible for the uncovered service.
I understand the financial policies of Texas Dentistry for Kids and agree to them
______________________________________
Signature of Responsible Party
______________
Date