New Patient Forms

Child's Information

Child's Name*

Nickname

Home Phone*

Age*

Birth Date

MM

DD

YYYY

Male
Female

Email Address*

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

Father or Guardian*

Social Security Number

Home Phone*

Cell Phone*

Birth Date

MM

DD

YYYY

Employer

Work Phone*

Mother or Guardian*

Social Security Number

Home Phone*

Cell Phone*

Birth Date

MM

DD

YYYY

Employer

Work Phone

Marital Status of Parents (check one)*

Dental History

Date of Last Dental Visit

Reason for this Visit

How often does your child brush?

Floss?

Does your child use a pacifier or suck a thumb or finger

Please describe how you think your child will behave today. Check all that apply.

Medical History

Name of Physician

Phone

Is your child currently taking any medication? If yes, what?

Is your child allergic to any medications? If yes, what?

Has your child ever been hospitalized? If yes, what?

Is your child currently under a physician’s care? If yes, why?

Has your child ever had any of the following? Please check box if YES*

What Allergies?

Last Echo?

Referral Information

Whom may we thank for referring you to our practice?*

Name of person or office referring you to our practice

Person Financially Responsible

Name

Relationship to patient

Home Phone

Work Phone

Address (if different)

Street Address Address Line 2 City State ZIP Code

Employer

Name of nearest relative not living with you

Phone

Primary Dental Insurance Company

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Group Number

Insured person’s name

ID number

Secondary Dental Insurance Company

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Group Number

Insured person’s name

ID number

Payment In Full Is Expected At Time of Treatment

Method of payment (Please Check One):

Check or Cash at Time of Service
Insurance Co-Payment at Time of Service
Credit Card
Payment Plan Option

All first-time patients are required to pay in full at time of treatment unless insurance is being utilized.
Patients with insurance must pay their estimated portion, including deductibles at the time of service unless prior arrangements have been made with office staff.
Please note that we submit insurance claims as a courtesy, it is the parent's/guardian's responsibility to see that the insurance company makes prompt payment.
I agree to pay for the balance of treatment that is not covered by the insurance company.
Any insurance balance over 60 days is due and payable by the parent/legal guardian.
I agree to pay the balance within 90 days (unless payment options have been arranged with the office staff) or the account will be turned over to an outside collection agency.
In the event any amount(s) is/are referred to a third party debt collection agency, I agree to pay additional interest, court costs, and reasonable attorney's fees. I will also be responsible for a collection fee of up to 40 % of the principal amount(s) owing.
I grant permission to the dentist to perform any necessary dental work for this child.
I agree to pay the doctor at the time of service for treatment rendered.
I agree to pay an interest rate of 1 1/2% per month (18% per annum) for unpaid balances over 60 days. Personal credit checks.
Your appointment time in our office is reserved for you because you are important to us. A $25.00 fee will be charged for appointments canceled, missed or rescheduled without 24 hours notice. Dismissal from our practice after 2 missed appointments.
I agree to pay $20.00 for all returned checks.
I authorize the release of any information in the course of the examination or treatment of the dentist.
I authorize payment to medical/dental benefits to the undersigned dentist for services described.
I agree to receive text appointment confirmations and/or any communications (including information regarding balances/collections) from Southridge Pediatric Dentistry.
I understand that as a parent/legal guardian bringing in my child, I am legally responsible for the payment of all fees.

Signature of Authorized Person:

Date

SOUTHRIDGE PEDIATRIC DENTISTRY

OFFICE POLICIES FOR SOUTHRIDGE PEDIATRIC DENTISTRY EFFECTIVE JANUARY 1, 2007

PAYMENT -

Payment is expected on the day of service. You will receive an estimate of your child's next treatment. This is only an estimate; you will be responsible for any remaining balance after insurance payments. We accept payments for 3 months. If a payment is missed, your account may be sent to an outside collection agency for further collections. Extended payment plans available through an outside financial company with approval of the application. We will also accept extended payment plans with the credit card and signature to run payments through monthly.

RETURNED CHECKS -

$20.00 will be added to your account for returned checks.

LATE TO AN APPOINTMENT -

If you are 15 minutes or more late for an appointment, you may be asked to reschedule that appointment. We schedule some appointments every 30 minutes and being I5 minutes late to an appointment will result in our other patients having to wait for their appointment. If you are going to be late, please call our office and we will let you know if you will need to reschedule.

MUSSED APPOINTMENT CHARGE -

Cancellation of appointments is required 24 hours in advance. A missed appointment charge of $25 . 10 per appointment will be assessed if notice is not given at least 24 hours in advance. This fee must be paid prior to the child's next visit. We will assist you in rescheduling all canceled appointments.

MULTIPLE MISSED APPOINTMENTS -

We reserve the right to refer treatment following two ( 2 ) "no show“ appointments or cancellation of more than 50% of scheduled appointments. We will assist you in locating another provider if continuing care is required. A missed appointment means another child could have received needed care at our clinic.

TEXT COMMUNICATION -

Our office sends out text appointment confirmations for your convenience. Under specific circumstances, a text message may be sent to you containing overdue balances/collections.

GENERAL ANESTHESIA APPOINTMENT -

If you fail to show up for a general anesthesia or IV sedation appointment, you will not be rescheduled for that appointment and will need to find another dentist to perform this service.

I have read, understand and agree to the terms of the above policy.

Parent/Guardian:

Date

HIPAA Notice of Privacy Practices

Southridge Pediatric Dentistry
2651 West 10400 South , Suite 103
South Jordan , Utah 84095
( 801 ) 4 46- 1515

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR COULD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

This Notice of Privacy Practices describes how we may use and disclose your or your child's protected health information ( PHI ) to carry out treatment, payment or health care operations ( TPO ) and for other purposes that are permitted or required by law. It also describes your rights to access and control your or your child's protected health information Protected health information " is information about you or your child, including demographic information , that may identify you or your child and that relates to your or your child's past present or future physical, dental or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information : Your or your child's protected health information may be used and disclosed by your or your child's dentist , our office staff and others of our office that are involved in your or your child's care and treatment for the purpose of providing health care services to you or your child , to pay you or your child's health or dental care bills , to support the operation of the dentist's practice and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, statement: We will or manage your or your child's health care and any related services. This includes the coordination or management of your or your child's health care with a third party. For example, we would disclose you're protected health the information, as necessary, to a hospital of the surgical center, specialty dentist or physician that provides care to you or your child. For example, your or your child's protected health information may be provided to whom you for your child have been referred to ensure that the physician has the necessary information to diagnose or treat you or your child .

Payment: Your or your child's protected health information ted health information will be used, as needed to obtain payment for your or your child's health care services. For example, obtaining approval for a hospital service may require that your or your child's relevant protected health information be disclosed to the health plan to obtain approval for the hospital service.

Healthcare Operations: We may use or disclose, as-needed, your or your child's your child's protected health information in order to support the business activities of your or your child's dentist. These activities include, but are not limited to, quality assessment activities, employee review activities. training of medical or dental students, licensing and conducting or arranging for other business activities. For example, we may call you or your child by name in the waiting room when your or your child's dentist is ready to see you. We may use or disclose your or your child's protected health information, as necessary to contact you to remind you of your or your child's appointment or recall status. We may use or disclose your of your child's protected health information for our Cavity Free Club and status.

We may use or disclose your or your child's protected health information in the in the following situations without your authorization. Those situations include: as Required By Law , Public Health issues as required by law , Communicable Diseases : Health Oversight ; Abuse or Neglect : Food and Drug Administration requirements : Legal Proceedings : Law Enforcement : Coroners , Funeral Directors , and Organ Donation : Research : Criminal Activity : Military Activity and National Security : Workers Compensation : Inmates Required Uses and Disclosures : Under the law, We must make disclosure to you and when required by the Secretary of the Department of Health and Human Services to investigate our compliance with the requirements of Section 164 . 500.

Other Permitted and Required Uses and Disclosure Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your or your child's dentist of has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights :TFollowing is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. : Under federal law, however, you may not inspect or copy to following records, psychotherapy notes: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected ealth information.

You have the right to request a restriction of your or your child’s proteted health information. : This means you may ask us not to use or disclose any part of your child’s health information for the purposes of treatment, payment or healthcare operations You may also request that any part of your or your child’s protected health informationnot be disclosed to family members or friends who may be involved in your or your child’s care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your or your child’s dentist is not required to agree to a restriction that your may request. If the dentist believes it is in your or your child’s best interest to permit use and discloser of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may ahve the right to have your or your child’s dentist amend your protected health information. :. If we deny your request for amendment, you have right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosers we have made, if any, of your child’s protected health information. We reserve the right to change the terms of this motice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your or your child’s privacy rights have been voilated by us. You may file a complaint with us bynotifying our privacy contact of your complaint.

We will not retalite against you for filling a compaint. This notice was published and becomes effective on / or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPA Compliance Officer in person or phone at our main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Pratices:

CAPTCHA

Child's Information

Parent/Guardian Information

Dental History

Medical History

Referral Information

Person Financially Responsible

Primary Dental Insurance Company

Secondary Dental Insurance Company

Payment In Full Is Expected At Time of Treatment

SOUTHRIDGE PEDIATRIC DENTISTRY

OFFICE POLICIES FOR SOUTHRIDGE PEDIATRIC DENTISTRY EFFECTIVE JANUARY 1, 2007

HIPAA Notice of Privacy Practices

Southridge Pediatric Dentistry
2651 West 10400 South , Suite 103
South Jordan , Utah 84095
( 801 ) 4 46- 1515

Let’s discuss how we can help your child improve their oral health.

COMPANY

SERVICE AREA

FOLLOW US ON SOCIAL MEDIA

New Patient Forms

Child's Information

Parent/Guardian Information

Dental History

Medical History

Referral Information

Person Financially Responsible

Primary Dental Insurance Company

Secondary Dental Insurance Company

Payment In Full Is Expected At Time of Treatment

SOUTHRIDGE PEDIATRIC DENTISTRY

OFFICE POLICIES FOR SOUTHRIDGE PEDIATRIC DENTISTRY EFFECTIVE JANUARY 1, 2007

HIPAA Notice of Privacy Practices

Southridge Pediatric Dentistry 2651 West 10400 South , Suite 103 South Jordan , Utah 84095 ( 801 ) 4 46- 1515

Let’s discuss how we can help your child improve their oral health.

COMPANY

SERVICE AREA

FOLLOW US ON SOCIAL MEDIA

Southridge Pediatric Dentistry
2651 West 10400 South , Suite 103
South Jordan , Utah 84095
( 801 ) 4 46- 1515