Pediatric HHF | Huntersville Smiles Orthodontics & Kids Pediatrics – Forms

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Pediatric New Patient Form
We would like to welcome you to our orthodontic family. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible! Thanks for your cooperation!
Patients’ Name * Required
First Middle Initial Last
Preferred Email * Required
Preferred Cell Phone * Required
Preferred method of communication * Required
- Home Phone
- Cell Phone
- Text / SMS
- Email

Additional Parent/Guardian Information
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Relationship to Patient
- Mother
- Step-Mother
- Father
- Step-Father
- Guardian
Parent/Guardian Name
First Middle Initial Last
Is the parent or guardian's home address different than the patients? * Required
- Yes
- No
Home Address * Required
Street Address City Zip Code
Cell Phone
Home Phone
Work Phone
Employer
Employer Address
Street Address City Zip Code

Responsible Party Information
Responsible Party Name * Required
First Last
Social Security No. * Required
Home Phone * Required
Work Phone
Responsible Party Address * Required
Street Address City Zip Code
Signature of Responsible Party
I accept responsibility for payment of all costs incurred with Huntersville Smiles Orthodontics & Kids Dentistry. I understand that, where appropriate, Credit Bureau reports may be obtained.

Dental Insurance
Do you have dental insurance? * Required
- Yes
- No

Dental Insurance Information
Insured Member * Required
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Relationship to Patient
Birthdate * Required
Insured's Employer * Required
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required
Insurance Company Address * Required
Street Address City State Zip Code
Policy Holder Signature * Required
I grant Huntersville Smiles Orthodontics & Kids Dentistry permission to bill my insurance for services/procedures rendered.
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Do you have secondary dental insurance? * Required
- Yes
- No

Secondary Dental Insurance Information
If you have additional dental insurance you would like us to be aware of, please include that here. Otherwise, you can skip this section, and continue with your application.
Subscriber Name
Relationship to Patient
Subscriber Birthdate
Insured's Employer
Insurance Company Name
Insurance Phone
Group Number
ID Number
Insurance Company Address
Street Address City State Zip Code

Acknowledgement Of Receipt Of Notice Of Privacy Practices
By signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request.
Signature of Parent/Guardian * Required

Please provide signature for Acknowledgement Of Receipt Of Notice Of Privacy Practices.

Consent to Treatment
Our office specializes in the dental health of children. We strongly believe in the early establishment of a dental home for your child that provides a safe and comfortable environment. To provide the best dental care, your consent regarding treatment, including preventative services, is required. Please read this form carefully, and we encourage you to ask any questions you may have.

I authorize Huntersville Smiles, with the support of a licensed dentist and/or dental auxiliaries, to perform the following dental treatment and/or oral surgery procedures for my child: necessary or advisable local anesthesia, fluoride radiographs (x-rays), photographs or diagnostic aids. Dental treatment may include one, or a number, of the following:
- Cleaning of the teeth and application of fluoride
- Application of sealants to the grooves of teeth
- Treatment of diseased or injured teeth with dental restorations
- Stainless steel crowns
- Extraction (removal) of one or more teeth
- Treatment of diseased or injured oral tissues (hard and/or soft)
- Treatment of malposed (crooked) teeth and/or developmental abnormalities with fixed or removable orthodontic appliances
- Behavior guidance using mouth prop, teel-show-do method, and/or voice control
- Protective stabilization including holding my child or the use of a papoose board
- Use of sedation medications and/or nitrous oxide to control apprehension
- Space maintainer(s) to prevent shifting of teeth
I understand that during treatment it may be necessary to change or add procedures based on health of tooth and/or child’s behavior. I give permission to the dentist to make any/all changes he/she deems necessary. The treatment has been explained to me and I understand that none of the above procedures will be performed without discussing the necessity with me and obtaining my consent to proceed. Alternative methods of treatment, if any, have been explained to me, along with their advantages, disadvantages, and risks. I am advised that good results are expected; however, the possibility and nature of complication cannot be accurately anticipated. Therefore, no guarantee, expressed or implied, can be given to me regarding this treatment.

Although their occurrence is rare and unpredictable, some risks are known to be associated with dental or oral surgery procedures, medications, and/or anesthetics. We are required to disclose the known risk or numbness, infection, aspiration (swallowing), swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, the loss of function of organs, or scarring. I understand and accept that complications may require medical assistance, hospitalization and in very rare cases death.

The American Academy of Pediatric Dentistry recommends fluoride be applied twice per year to help aid in the formation of tooth enamel, to repair early stages of tooth decay, and to help prevent decalcification. For this reason, please be aware that this will be applied at each cleaning unless otherwise notified.
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Name of Patient * Required
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Parent/Guardian Name * Required
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Relationship to Patient * Required
- Mother
- Step-Mother
- Father
- Step-Father
- Guardian
Signature of Parent/Guardian * Required
I hereby state that I have read and fully understand this consent, I have been given an opportunity to ask questions regarding this consent and proposed treatment and understand that treatment and available options will always be discussed with me in detail prior to commencing work. I also understand that this consent will remain in effect until such time that I choose to terminate. Such termination of consent must be in writing.

Our Practice Policies
Financial Policy

Welcome to our practice! We value the importance of a relationship with your family founded on trust and communication. The following information will outline our office’s financial policy. We welcome any questions you have and will do our best to answer them adequately.

Payment Policy

Please be aware that the parent who brings the child to his or her appointment is legally responsible for the payment of all charges. This parent is responsible for payment of fees regardless of pre-existing custody agreements or court orders. As a fee-for-service practice, we require payment at each appointment for services rendered that day. We accept Visa, Mastercard, Discover, cash and personal checks, CareCredit, and AMEX. Additionally at $35 returned check fee will be assessed as applicable.

An insurance policy is a contract between you as a subscriber and the carrier of your insurance. It is your responsibility to understand your benefits policy. For our patients with insurance, we will file your claims for you as a courtesy. Generally, the portion not covered by your insurance benefit is payable at the time of treatment unless a written pre-treatment estimate is obtained from your insurance company prior to the appointment. Signing this form constitutes authorization to release personal health information companies for reimbursement purposes.

Balances over 30 days are considered past due and a late fee of $25 may be due. If your account becomes past due, the account may be turned over to a collection agency if no effort or response is made on your behalf to resolve. We may be obligated to report your account status to any credit reporting agency. If you have any questions concerning this policy, please ask to speak with our Practice Manager.

Appointment Policy

In consideration of our patients that are waiting to be scheduled, broken appointments or appointments cancelled without a 24-hour notice may result in an additional $50 failed appointment fee. Additionally, cancelled appointments without proper notice may result in pre-payment of services prior to the visit being rescheduled. The time we reserve for your child’s dental appointment is very important and Huntersville Smiles Kid’s Dentistry will confirm your appointment 2-3 days prior to your scheduled appointment.
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Name of Patient * Required
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Parent/Guardian Name * Required
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Relationship to Patient * Required
- Mother
- Step-Mother
- Father
- Step-Father
- Guardian
Signature of Parent/Guardian * Required
By signing below, you have read and understand the importance of the above practice policies.

Signature
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I grant authority to Huntersville Smiles Orthodontics & Kids Dentistry to perform all procedures and treatments in the patient's best interest.
Signature of Parent/Guardian * Required

Step 1 of 13

Pediatric New Patient Form

Patient Information

Parent/Guardian Information

Additional Parent/Guardian Information

Responsible Party Information

Dental Insurance

Dental Insurance Information

Secondary Dental Insurance Information

Patient Dental History

Do you have any of the following concerns about your child's mouth/teeth?

Has the patient ever HAD or PRESENTLY HAVE any of the following habits?

Patient Medical History

Has the patient ever HAD or PRESENTLY HAVE any of the following?

Is your child allergic to any of the following medications?

Is your child allergic to any of the following?

Authorization of Release

Who can Huntersville Smiles provide information on your behalf?

Patient Rights

Acknowledgement Of Receipt Of Notice Of Privacy Practices

Consent to Treatment

Our Practice Policies

Financial Policy

Payment Policy

Appointment Policy

Signature