Michael A. Crist, D.D.S., P.C.
Specialist in Pediatric Dentistry & Orthodontics
Welcome to our practice! Please complete this form front and back.
Patient’s Name: ______
Last First Middle Initial Call name
Patient Address: ______
______Age:______
City State Zip
Phone Number: ______Patient Date of Birth: ______
Patient Medical History: (circle all that apply)
Heart Murmur Congenital Heart Defect Cancer Abnormal Bleeding
Diabetes Rheumatic Fever HIV/ AIDS Any Operations
Asthma Hepatitis Tuberculosis Any Stays in Hospital
Convulsions/Epilepsy Hearing Impairment Hemophilia Handicaps/Disabilities
Kidney/Liver Problems Headaches Prosthesis Allergies to Any Drugs
History of Scarlet Fever Food Allergies Latex Allergy
Please discuss any serious medical problems that the child has/had or other medical information that may apply:
______
**Does the patient need antibiotic medication prior to a cleaning? Yes/ No
**Is the Patient Pregnant? Yes/ No
***Has the patient tested positive for AIDS or HIV? Yes/ No
Account Information:
Who is with the child today? Name:______
Billing Address: ______Home Phone#: ______
City State Zip
Relationship to Patient: ______Do you have legal custody of this child? Yes/No
Father’s Information: Name: ______Home #______
Employer: ______Work #: ______
Date of Birth: ______Social Security #______Texas License #______
Mother’s Information: Name: ______Home #______
Employer: ______Work #: ______Date of Birth: ______Social Security #______Texas License #______
Insurance Information:
Name of Insurance Carrier: ______Group/Policy #: ______
Insurance Carrier Address: ______
______Insurance Phone Number: ______
Name of Insured Employee: ______Relationship to Patient: ______
Insured Date of Birth: ______Insured’s Employer: ______
Social Security Insured: ______Insured Marital Status: ______
I understand the information that I have given is correct to the best of my knowledge, that it will me held in the strictest 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.
______Date: ______
Signature Parent/legal guardian
Michael A. Crist, D.D.S., P.C.
Specialist in Orthodontics & Pediatric Dentistry
Welcome to our office!!! We are committed to providing you with the best possible care.
(Please read and initial each line)
______Payment for services is due at the time services are rendered unless arrangements have been approved in advance by our staff. We accept checks and most major credit cards.
______The parent/legal guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.
______If you have an insurance plan, we will be happy to assist you in claiming your benefits. Please provide us with a completed dental claim form and a copy of your dental insurance card.
______Insurance policies and payment programs can be confusing; we require that patients contact their insurance company to confirm that their assumptions regarding coverage for dental treatment are correct. Please request this information in writing from your insurance company. Patients must realize that professional services are rendered to a person, not an insurance company. The insurance company is responsible to the patient and the patient is responsible to us. We cannot render services on the assumption that the charges will be paid by an insurance company. However, we will help in any way we can.
______Returned checks will result in a $30.00 charge to your account.
______Any cost associated with the collection of payment for services rendered will be paid by the responsible party. Accounts with balances older than 90 days may be subject to additional collection fees and interest charges of 1.75% per month.
______24 hours notice is required to cancel an appointment. Missed appointments will result in a Charge of $35.00.
______Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. I understand that all State and Federal OSHA regulations are strictly adhered to.
______Our office limits all pediatric dental appointments to Saturday due to an existing full-time orthodontic practice. Weekday appointments are limited to emergencies.
Please feel free to ask our staff any questions you may have regarding the above information. We are here to help you.
______I, as the Responsible Party, acknowledges that I have reviewed the above information and that I understand it completely.
______
Parent/Legal Guardian Date
FOR OFFICE USE ONLY**** FOR OFFICE USE ONLY**** FOR OFFICE USE ONLY****
1. Date: ______Comments: ______Parents: ______
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ______Date: ______Dr Comments: ______
1. Date: ______Comments: ______Parents: ______
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ______Date: ______Dr Comments: ______
1. Date: ______Comments: ______Parents: ______
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ______Date: ______Dr Comments: ______
Michael A. Crist D.D.S.
Specialist in Orthodontics & Pediatric Dentistry
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
SECTION A: PATIENT/PARENT GIVING CONSENT
Patient Name: ______
Address: ______
Telephone: ______Parent email: ______
Parent Name: ______Parent Social Security #:______
SECTION B: TO THE PATIENT/PARENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy practices before you decide whether to sign this Consent. Our Notice Provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available upon request at the reception desk. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Michael A. Crist, DDS
13303 Champion Forest Dr. #10
Houston, Tx 77069-2650
281-444-1735
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
SIGNATURE
I, ______, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. I have received a copy of this office’s Notice of Privacy Practices.
Parent Signature: ______Date: ______
Relationship to Patient: ______
Insurance Information
If you have an insurance plan that pays dental benefits, we will be happy to assist you in claiming your benefits. With increasing numbers of dental insurance programs, we find it impossible to have a complete and accurate knowledge about all of these programs and our individual patient's status with respect to his own program. Please be advised that our office does not participate in discount dental programs, HMO or DMO plans for pediatric dentistry. In order to process your insurance claim properly, we will need the following information and a copy of your dental insurance card.
Patient Name: ______Date of Birth: ______
Address: ______Phone: ______
City/State/Zip: ______
Relationship to Insured Employee: Child / Spouse / Self / Other Sex: Male / Female
Insured Employee Information: Primary insurance
Name: ______Date of Birth: ______
Social Security# or Insurance ID# :______(required)
Address: ______
City/State/Zip: ______
Employer Name: ______Group #:______
Insurance Company Name: ______Phone Number: #:______
Claims Mailing Address: ______
______
Is Patient Covered by another insurance plan? Yes / No
Insured Employee Information: Secondary insurance
Name: ______Date of Birth: ______
Social Security# or Insurance ID# :______( required)
Address: ______
City/State/Zip: ______
Employer Name: ______Group #:______
Insurance Company Name: ______Phone Number: #:______
Claims Mailing Address: ______
______
I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted under applicable law. I authorize release of any information relating to this claim.
X______
Signed (Patient/Guardian) Date (MM/DD/YYYY)
I hereby authorize payment of the dental benefits otherwise payable to me directly to Michael A Crist D.D.S:
X______
Signed (Patient/Guardian) Date (MM/DD/YYYY)
Insurance policies and payments can be confusing; we require that patients contact their insurance company to confirm that their assumptions regarding coverage for dental treatment are correct. Please request this information in writing from your insurance company. Patients must realize that professional services are rendered to a person, and not an insurance company. The insurance company is responsible to the patient and the patient is responsible to us. We cannot render services on the assumption that the charges will be paid by an insurance company. However, we will help in any way we can.