Cooper Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Required

Middle Initial

Patient Last Name

Required

Date of Birth

Required

Gender

Male Female

Required

Name and occupation of person fillling out form

Are you the legal guardian?

Yes No

Marital Status

Married Single Other

Required

Other

Email

Home Phone

Work Phone

Extension

Mobile Phone

Best time to call

Preferred Methods of Contact (choose one or more)

Text Email Mobile Phone Home Phone

Address

City

State

Zipcode

Name and age of brothers and sisters

Are any siblings presently patients of our office (or have appointment scheduled already)?

Yes No

How did you hear about us?

Other

Who may we thank for referring you?

First Name

Last Name

Insurance Information

Insured First Name

Insured Last Name

MI

Insured's Birth Date

Social Security #

Patient's relationship to insured

Insured's Address

City

State

Zip Code

Insured's Employer Name

Employer Address

City

State

Zip Code

ID #

Group #

Insurance Plan Name

Insurance Address

City

State

Zip Code

Child’s Medical History

Primary Care Physician

Phone Number

Date Of Your Child's Last Physical

Please Answer Yes/No To The Following

ADD/ADHD

Yes No

Asthma

Yes No

Autism

Yes No

Bleeding/ Blood Disorder

Yes No

Chronic Nose/ Throat

Yes No

Diabetes

Yes No

Ear Infections

Yes No

Gag Reflex

Yes No

Murmur

Yes No

Heart Disease

Yes No

Reflux

Yes No

Seizures

Yes No

Snoring

Yes No

Speech Pathology

Yes No

Vision or Hearing Disorders

Yes No

Is there any other condition that our office should know of that is not listed above?

Yes No

Please explain or list the condition below

Is your child taking any medications?

Yes No

List the medications

Has your child had any hospitalizations/surgeries?

Yes No

Please explain

Does your child have any allergies/ reactions to the following: antibiotics, anesthetics, medications, latex,foods or other substances?

Yes No

Please elaborate

Dental Health History

Reason for today's visit

Is this your child's first dental visit?

Yes No

Required

Date Of Last Visit

Dentist Name

Phone Number

Were xrays taken?

Yes No

How would you describe the experience?

Why did you leave the dental practice?

Has your child ever had a cavity?

Yes No

Has your child ever had dental treatment?

Yes No

Please describe

Has your child suffered from any injuries to teeth or jaws?

Yes No

Please explain

List any oral habits (e.g. thumb, pacifier, or clenching) your child may have

If your child is an infant/toddler, do they nurse or use a bottle?

Yes No

Do they nurse or use a bottle to sleep?

Yes No

What type of toothbrush does your child use?

Manual Motorized

Do you assist or supervise with brushing?

Yes No

Does your child use a fluoride toothpaste?

Yes No

Can they spit it out?

Yes No

How often does your child brush their teeth per day?

None 1X 2X

Does your child use fluoride mouthrinse or prescription toothpaste?

Yes No

Does your child take fluoride supplements?

Yes No

Does your child take iron supplements?

Yes No

Does your child take chewable or gummy vitamins?

Yes No

Does your child frequently have a diet high in sugar content?

Yes No

Has your child had any orthodontic treatment?

Yes No

Name Of Orthodontist

Phone Number

Do you (parent) have a dentist?

Yes No

Dentist Name

Phone Number

Is there a family history of cavities?

Yes No

Useful Phrases, Words, Or Actions That Work Best With Your Child Or Any Additional Information That May Help Us To Prepare For a Sucessful Dental Experience:

How do you expect your child to behave today?

Well Poorly Unsure

Required

Comments

To the best of my knowledge, all of the preceding answers are true and correct. IF the patient has a change in health or medicines, NY Pediatric Dentistry will be informed. The parent/ legal guardian whose signature appears, consents to treatment as explained by our office and is responsible for all fees at the time of services rendered, if we are not an in‐network provider for your insurance. Claims will be electronically forwarded at the time of visit so reimbursement can be promptly made.

INSURANCE is a contract between an employer and a dental insurance company. Benefits received are based on the terms of the contract that was negotiated between the employer and that insurance company, not NY Pediatric Dentistry. If we are a provider for your insurance, we will do everything possible to make the most of your benefits so that out of pocket costs are limited. Please be aware that ultimately the responsibility of any expenses after insurance reimbursement to us lies with you. Many policies provide only basic coverage for dental services. Benefits occasionally do not cover those services necessary to achieve a high quality, safe result, especially in pediatric dentistry. By signing below you understand the above explanations regarding the possible limitations of your policy and will be familiar with it coverage prior to treatment.

NOTICE OF PRIVACY ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability and Accountability Act of 1998 (HIPAA), I have certain rights to privacy regarding my protected health information. I have received (available on our website or at front desk), read and understand the Notice of Privacy Practices containing a more complete description of uses and disclosures of my health information. I understand that NY Pediatric Dentistry has the right to change its Notice of Privacy Practices from time to time and that I may contact them at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing how my private information is used or disclosed to carry out treatment, payment or health care operations.

I grant NY Pediatric and Adult Dentistry permission to contact previous dental practitioners for records/ radiographs as part of treatment for my child’s oral health care.

Click on the hyperlink to read or obtain a copy of our Notice of Privacy Practices:

Notice of Privacy Practices

CONSENT FOR INTERNET COMMUNICATIONS

I have read the information regarding the secured uploading of patient information to the NY Pediatric Dentistry web site, and grant the permission to securely upload my information. If needed, a copy of the Consent for Internet Communication or Notice of Privacy Practices will be provided by the office or it is always available on the website.

Signature

Clear

Clear

Required

Date

Required

Print Name

Relationship to Patient:

PATIENT REGISTRATION INFORMATION

Insurance Information

Child’s Medical History

Please Answer Yes/No To The Following

Dental Health History

NOTICE OF PRIVACY ACKNOWLEDGEMENT

CONSENT FOR INTERNET COMMUNICATIONS

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