Child Registration - Los Angeles Center for Endodontics

Create Smiles Dental

Philip M. Chang, DDS

1611 Crenshaw Blvd. #C, Torrance, CA 90501

Child Online Registration

Patient Name

Date of Birth

Age

School

Grade

Sex

Male Female

Date of Last Physical

Address

City

State

ZIP

Emergency Contact Name

Relationship to Patient

Phone

Name of Physician

Physician's Address

Medical History

How is the general health of your child?

Has your child experienced any serious illness (rhematic fever, diabetes, hepatitis, kidney disease, jaundice, tuberculosis, anemia)?

Yes No

Does your child have any unusual physical condition (heart defect, developmental defect, or neuromuscular defect such as cerebral palsy)?

Yes No

Does your child have asthma or any lung conditions which cause breathing difficulty?

Yes No

Has your child ever been hospitalized? Explain why and when.

Yes No

Does your child bruise easily or bleed unusually long after a cut?

Yes No

Does your child have allergies (latex, food, or other)?

Yes No

Has your child ever experienced any unusual reaction to any drug or any anesthetics?

Yes No

Is your child currently taking any medication or receiving any drug therapy?

Yes No

How would you describe your child’s general behavior?

DENTAL HISTORY

What is the chief reason for this visit?

When was your child’s last dental examination?

Has your child received dental care before? If yes, briefly describe the age, the behavior and the treatment received.

Yes No

Has your child experienced any major injury to the face or teeth? If yes, explain how and when.

Yes No

Does your child have any oral habit such as finger sucking and pacifier use?

Yes No

DIET/ORAL HYGIENE

What are his/her usual snacks and how many times a day?

Who brushes the child’s teeth and how many times a day?

Person Responsible for Payment

Name

Relationship

Date of Birth

Social Security #

Driver's License #

Dental Insurance Information

Dental Insurance Primary Carrier

Insured's Name

Date of Birth

Social Security #

Insurance Company

Group #

ID #

Address

Insured's Employer

Dental Insurance Secondary Carrier

Insured's Name

Date of Birth

Social Security #

Insurance Company

Group #

ID #

Address

Insured's Employer

AUTHORIZATION AND RELEASE

Agreement 1

The above information is accurate and complete to the best of my knowledge and is only for use in treatment, billing and processing of insurance for benefits to which my child is entitled. If my child ever has any changes in his/her health, or if his/her medicines change, I will inform the Doctor of Dentistry at the next appointment without fail. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care, to third party payers and/or other health practitioners. I authorize my insurance company to pay directly to the dental office the benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my child’s behalf.

Agreement 2

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Agreement 3

Since the office has other patients urgently seeking dental care, we strongly encourage that you keep your appointment. I understand there will be $50 broken appointment charge if I fail to give 24 hours advance notice.

Agreement 4

I consent to signing this document electronically by printing my first and last name below.

Signature of Parent of Minor

Date