Orthodontic Child New Patient Form

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We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us!

 

_2017 Child Registration Form – Ortho

Patient Information

Gender:
Phone Type
OK to leave message?

Parent / Guardian Information

Parent 1

Marital Status
Relation to Child:
Phone Type:
Phone Type:

Parent 2

Marital Status
Relation to Child::
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Has your child visited an orthodontist before?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply):

Medical History

Is your child currently being treated by a physician?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

Authorization

Assignment of Benefits (if covered by insurance): I direct that my insurance company pay the benefits for treatment directly to McCalla Orthodontics and Pediatric Dentistry. I assign to the dental office for the purpose of security, any right I may have to receive such payment directly from the insurance company, and hereby revoke any prior authorizations which I may have given to the contrary. I agree to cooperate fully with the office efforts to obtain payment under such policy and will execute any additional documents my insurance company may require in order to process the office claim. In the event of any overpayment of insurance benefits, (as where two policies are subject to a coordination of benefits) I authorize McCalla Orthodontics and Pediatric Dentistry to refund to the company making such over payment.

Payment Policy: I understand that by signing below I agree to pay for services rendered, whether or not I am the patient. I agree that I will pay this bill in full whether or not charges are or should have been covered by insurance. I have been advised that the office does not extend credit and that payment is due in full at time of service. I agree that if this account is not paid when due, and if the office should refer it to an attorney or collection agency for collection, I agree to pay collection agency fees (33.33%), attorney fees and/or court costs. I also agree to pay interest on past due balances of 1.5 % per month (18 % APR). I hereby waive all rights of emption which are available to me under the law of Alabama or the United States.

Any returned checks will be assessed a $35.00 charge. By law, your bank informs you of a dishonored check. We expect you to contact us to make arrangements for settling the full amount of the check plus $35.00 within ten (10) days. Late payment charges will be assessed if the matter is not settled by that time. All other policy provisions as noted above apply, including collection.

We thank you for your cooperation and look forward to providing the highest quality dental care for your children with a clear understanding of each party's responsibilities.

Appointment Cancellation Policy: We require a 48 hour notice of change in appointments. We reserve the right to charge a $40.00 fee for missed appointments and appointments changed with less than 48 hour notice.

Telephone Consumer Protection Act (TCPA): You agree, in order for us to service your account or to collect monies you may owe, McCalla Orthodontics and Pediatric Dentistry, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using prerecorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and financial policy and accept all provisions. I/We also agree that McCalla Orthodontics and Pediatric Dentistry, its employees and/or agents may contact me/us as described above.



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