Children’s Smiles Start Here www.CaseyDentalDDS.com Patient Information Child’s Full Name Age Name Called By Birthday / / Sex: MF Place of Birth Child’s Home Address City State Zip Code Home Phone ( ) Child’s Favorite Hobbies/Interests Other Siblings (Names & Ages) (Names & Ages) Child’s Physician Phone ( Address Date of Last Exam What is your Child’s Current Weight? ) What is your Child’s Current Height? Parent/Guardian Information Parent/Guardian Name Social Security # Relationship to Patient: - - Date of Birth: Employer Work/Mobile Phone ( Parent/Guardian Name Social Security # Relationship to Patient: - - Date of Birth: Employer Work/Mobile Phone ( Marital Status Married ) Divorced Widowed Separated ) Partner Other Email Address How would you like to be contacted? ___ Phone ___ Email ___ Text How did you find out about our office? Medical History Please indicate with a YES or NO. Does your child currently have/previously had any of the following health problems? Allergies (Latex, Penicillin, Eggs, Nuts, Food, High/Low Blood Pressure Dust, Drug, Unknown) If yes, Please List Any Current/Recent Injuries Childhood Illnesses Rheumatic Fever / Rheumatic Heart Disease Blood Transfusion Congenital Heart Disease or Heart Murmur Any Prolonged Bleeding/Bruises Easily If yes, Premed Needed? Kidney or Bladder Problems Name of Pharmacy: Tuberculosis or Pneumonia Pharmacy Phone Number: Liver Problems, Jaundice or Hepatitis Glandular or Hormonal Problems Accidents or Severe Infections Diabetes/Blood Sugar Problems Psychological or Emotional Problems Casey Dental DDS | 204 West Arlington Blvd Suite B | Greenville, NC 27834 | Phone (252) 751-‐0556 Fax (252) 751-‐0564 Medical History (continued) Arthritis or Rheumatism (painful, swollen joints) Any Pending/Recent Surgery Convulsions, Seizures, Fainting or Epilepsy Speech, Learning, or Hearing Disorders Anemia or Blood Disorders Asthma or Hay Fever (Please Indicate) If yes, please list any current medications: Are your child’s Immunizations Current? Does your child have any special needs or special circumstances? (i.e. Autism, Cerebral Palsy, Downs Syndrome): Dental History Date of Last Dental Visit By Dr. Do you have any Current Records (including x-rays) from another practice? Yes No No Has your child complained about any dental problems? Any injuries or surgeries to mouth, teeth, head? Yes No If yes, please describe Does your child still take the bottle or sippy cup? What does your child usually drink? Does your child brush daily? Yes No How Often? Do you assist your child w/Brushing? Is Dental Floss used? Yes Yes No How Often? No Please check each box if your child has any of the following mouth habits Thumb Sucking Mouth Breathing Pacifier Nail Biting Finger Sucking Grinding Other How does your child receive Fluoride? Water Supply Dentist Toothpaste Vitamins Tablets None Other: Child’s Attitude Towards Dentistry: Reason for Today’s Visit/Chief Concerns: I hereby certify that all of the above information is correct and true. Because the above-named child is a minor, it is necessary that a signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment can be commenced. I agree to diagnostic procedures and dental treatment as found by Dr. James Casey II, DDS or doctors working with Dr. James Casey II, DDS for the patient named above. Furthermore, I will accept full responsibility for any professional fees incurred for dental services for my child. I understand that I am responsible for all charges whether or not covered by insurance. Relationship to Patient Signed Date Casey Dental DDS | 204 West Arlington Blvd Suite B | Greenville, NC 27834 | Phone (252) 751-‐0556 Fax (252) 751-‐0564 _______________________________________________________________________ Casey Dental Dr. Jim Casey, DDS ____________________________________________________________________ Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: _______________________________________ ____________________________________________________________ ____________________________________________________________ I have received a copy of the Notice of Privacy Practices for the above named practice. _______________________________ Signature _____________________ Date For Office Use Only We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:  An emergency existed & a signature was not possible at the time.  The individual refused to sign.  A copy was mailed with a request for a signature by return mail.  Unable to communicate with the patient for the following reason: _____________________________________________________  Other:________________________________________________ ________________________________________________ Prepared By __________________________________________ Signature __________________________________________ Date __________________________________________ 204 W. Arlington Blvd., Suite B Greenville, NC 27834 Phone 252-751-0556 Fax 252-751-0564 www.caseydentaldds.com Authorization for Release of Information – Compound Release Name of Patient ________________________________________________ Date of Birth ______________ _______________________________________________ is authorized to release protected health information about the above named patient in the following manner and to identified persons. Entity to Receive Information. Check each person/entity that you approve to receive information. Description of information to be released. Check each that can be given to person/entity on the left in the same section.  Voice Mail  Other person (s) (provide name and phone number)  See notarized document  Email communication-Provide email address* ____________________________________ *For email communication to occur, please accept the disclosure below:  Text communication – Provide number * ____________________________________  Financial  Dental  Financial  Medical  Appointment reminders  Breach notification  Appointment reminder  Other: ____________________________________ *For text communication to occur, accept the disclosure below:  For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.  Photo of patient received by patient or legal guardian  Photo taken by staff (Example: pre/post procedure)  Other  May be posted in office  May be posted on website  Other________________________________ Patient Rights:      I have the right to revoke this authorization at any time. I may inspect or copy the protected health information to be disclosed as described in this document. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization will remain in effect until revoked by the patient. _________________________________________________________ Date ___________________ Signature of Patient or Personal Representative *Description of Personal Representative’s Authority (attach necessary documentation) Revised Oct 2014