Today`s Date: File #. Child`s Name: Child`s Nickname: u Boy u Girl

Who is accompanying this child today?
File #.
Today's Date:
Child's Name:
LAST
MI
FIRST
❑ Boy ❑ Girl
Child's Nickname:
Child's Birthdate:
RELATION TO CHILD
Do you have Legal Custody of this Child? ❑ Yes
How many Brothers/Sisters?
Age:
School:
FULL NAME (IF OTHER THAN PARENT)
Grade:
MOTHER'S NAME
❑ STEP MOTHER
❑
No
Age(s):
❑ GUARDIAN
EMAIL ADDRESS
Child's Home Phone #:(
( ❑ CHECK IF SAME AS CHILD'S) HOME ADDRESS CITY
Child's SS#:
(
)
HOME PHONE #
Child's Address:
HOME ADDRESS
STATE
ZIP
MOTHER'S SOCIAL SECURITY #
)
/
DATE OF BIRTH
MOTHER'S DRIVERS LIC. #
Employer:
Referred By:
ZIP
WORK PHONE #
/
CITY
STATE
How Long?
(If doctor, please give address & phone number.)
EMPLOYER'S ADDRESS
FATHER'S NAME
CITY
❑ STEP FATHER
❑ GUARDIAN
EMAIL ADDRESS
( ❑ CHECK IF SAME AS CHILD'S) HOME ADDRESS CITY
Primary Dental Insurance
)
HOME PHONE #
/
Address:
FATHER'S SOCIAL SECURITY #
EXT.
/
FATHER'S DRIVERS LIC. #
DATE OF BIRTH
How Long?
Employer:
ZIP
STATE
CITY
ZIP
STATE
WORK PHONE #
Co. Name:
ZIP
STATE
ZIP
STATE
CITY
EMPLOYER'S ADDRESS
Phone #:
Insured's ID#:
Group #
(Plan, Local, or Policy #):
Insured's Name:
Date of Birth:
Relation:
d
/
/
Insured's Employer:
Does either policy cover Orthodontics? ❑ Yes ❑ No
Secondary Dental Insurance
Person ultimately responsible for account
Name:
RELATION TO CHILD
Billing Address:
Co. Name:
ZIP
STATE
Address:
/
ZIP
STATE
CITY
Phone #:
/
DATE OF BIRTH
SOCIAL SECURITY #
)
WORK PHONE #:
EXT.
Payment method:
❑ Cash
DRIVERS LIC. #
CELL PHONE #:
❑ Check
Insured's ID#:
Group #
❑
(Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Employer:
Date of Birth:
/
/
Credit Card -
Enter card # above (if accepted)
I hereby authorize assignment of my insurance rights and
benefits directly to the provider for services rendered. I fully
understand I am solely responsible for any balance not paid by my
insurance company (if offered at this office).
Initials
Pieusc Continue On Bock
❑ Exam
Reason for today's visit:
C
40_
❑ Emergency
[LI Consultation
Is Child in pain? ❑ No ❑ Yes How Long'?
Please indicate j any of the following problems:
❑ Discomfort, clicking or popping in jaw. ❑ Lost/Broken Filling(s)
❑ Red, swollen or bleeding gums.
❑ Teeth grinding
❑ Sensitive tooth, teeth or gums.
❑ Ringing in Ears
❑ Blisters/Sores in or around the mouth. ❑ Broken/Chipped tooth
❑ Other(s):
Does child require pre-medication? ❑ Yes ❑ No ❑ Don't know
❑
❑
❑
❑
Stained teeth
Locking Jaw
Bad breath
Loose tooth
Previous Dentist:
Last Dental exam:
/
/
Last Dental X-rays:
/
/
Times a day child brushes?
Times a week child flosses?
Is the child's water fluoridated? ❑ Yes ❑ No
How would you rate the child's smile? Best 1 2 3 4 5 6 7 8 9 10
'•\
r
t7/
Is Child taking any of the following medications? ❑ Pain killers (,INCLUDING ASPIRIN) LI Ritalin ❑ Stimulants
❑ Blood Thinners ❑ Tranquilizers ❑ Insulin ❑ Muscle relaxers ❑ Others:
Child's Physician:
DOCTOR'S NAME OR CLINIC NAME
PHONE#
Last Medical Exam:
ADDRESS
CITY
STATE
ZIP
Does Child have or ever had any of the following diseases, medical conditions or procedures?
Y N Heart Murmur
Y N Rheumatic fever
N Tonsillitis
Y N High/Low Blood Pressure
Y N Artificial Heart Valves
Y N Congenital Heart defect
Y N Respiratory Problems
Y N Asthma/Difficulty Breathing
Y N Hepatitis
Y N Artificial Bones/Joints/Implants
Y N Blood Transfusion(s)
Y N Scarlet Fever
Y N Leukemia/Anemia
Y N Liver/Kidney/Organ Problems
Y N HIV+/AIDS/ARC
Y N Surgeries/Operations
Y N Diabetes/Hypoglycemia
Y N Tuberculosis TB
Y N Cancer/Tumors
Y N Hemophilia
Y N Abnormal Bleeding
Y N Chemotherapy
Y N Jaw Problems TMJ/TMD
Y N Cleft Lip/Palate
Y N Psychiatric Problems
Y N Hyper Active/ADD
Y N Fainting/Seizures/Epilepsy
Y N Hearing Problems
Y N Birth Defects
Y N Cerebral Palsy
Please list any other medical condition(s) child has or ever had:
Is Child allergic to: ❑ Latex ❑ Penicillin/Amoxicillin ❑ Tetracycline ❑ Dental Anesthetics (Novocaine)
❑ Aspirin ❑ Food allergies ❑ Other(s):
Does child wear contact lenses? ❑Yes ❑ No
Please rate the child's general health from 1-10:
Has this child ever taken the drug Ritalin? ❑ No ❑ Yes/How long?
Does this child do any of the following? ❑ Thumb/Finger Sucking
Mouth Breathing ❑ Lip Sucking/Biting
❑ Heavy Snoring
Child's Blood type:
❑ Tongue Thrusting/Sucking
❑
■ We invite you to discuss with us any questions regarding our services. The best Dental health services are based
on a friendly, mutual understanding between provider and patient.
■ Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been
made with the business manager. If account is not paid within 90 days of the date of service and no financial
arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and
any other expenses incurred in collecting your account.
■ I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the
provider to release any information required to process insurance claims.
■ I understand the above information and guarantee this form was completed correctly to the best of my knowledge
and understand it is my responsibility to inform this office of any changes to the information I have provided.
Date
Signature
Parent or Guardian
J
Other .
First Impression Forms, Inc. 1-800-99FORMS FORM # 1DGC2 Copyright © 2010
Worst
DR. LISA WYATT
5037 VETERANS BLVD STE 3E
METAIRIE, LA 70006
504-885-1039
AGREEMENT FOR TREATMENT IN OUR PRACTICE.
1) A LEGAL GUARDIAN MUST ACCOMPANY THE CHILD (ANYONE
UNDER AGE 18) AT ALL TIMES FOR ALL APPOINTMENTS. THIS
- MEANS ONLY LEGAL PARENTS, NOT GRANDPARENTS, OR
FRIENDS OF PARENTS EVEN IF THE CHILD LIVES WITH THEM.
YOU MAY NOT LEAVE WHILE THEY ARE HERE. THIS IS A STATE
LAW. WE DID NOT MAKE THE LAW, BUT WE MUST FOLLOW IT.
2) IF YOU MISS THREE APPOINTMENTS WITHOUT A 24 HOUR
NOTICE, YOU WILL BE DISMISSED FROM OUR PRACTICE.
3) YOU MUST ARRIVE AT YOUR SCHEDULED APPOINTMENT TIME,
THIS IS NOT A CLINIC. IF YOU ARE LATE, ALL THE REST OF THE
PATIENTS WILL HAVE TOWAIT BECAUSE OF YOU.
4) IF YOU WANT US TO FILE FOR YOUR INSURANCE FOR YOU, YOU
MUST PROVIDE PROOF OF INSURANCE OR PAY AT THE TIME OF
YOUR APPOINTMENT.
PATIENT SIGNATURE:
PARENT SIGNATURE:
( NEEDED FOR ALL MINORS)
DATE:
LISA WYATT, DDS
5037 VETERANS BLVD STE 3E
METAIRIE, LA 70006
PH (504) 885-1039
FINANCIAL POLICY AGREEMENT
I agree to be responsible to pay in full for all services rendered at time of visit, unless
other arrangements have been made with the business manager. If account is not paid
within 90 days of the date of service and no financial arrangements have been made, you
will be responsible for delinquent billing fees, legal fees, collection agency fees, interest
charges and any other expenses incurred in collecting your account.
Sign
Date
FINANCIAL POLICY AGREEMENT
ACKNOWLEDGEMENT OF RECEIPT:
NOTICE OF PRIVACY PRACTICES
EFFECTIVE AS OF 03/18/2014
By signing below you acknowledge that you have received, read and understand Lisa
Wyatt DDS's (the "Practice") Notice of Privacy Practices ("Notice"). This Notice
provides information about how we may use and disclose your Protected Health
Information. If you have any question about the Notice, please contact the Practice's
Privacy Officer at 504-885-1039 and ask for Dr. Lisa Wyatt.
ACKNOWLEDGEMENT OF RECEPT: I acknowledge receiving, reading and
understanding Lisa Wyatt DDS's Notice of Privacy Practices
Signature of Individual
Date
Personal Representative's Section:
, hereby certify that I am the personal
and warrant that I
representative of
have the authority to sign this Authorization on the basis of:
Signature of Personal Representative
Date
Internal Use Only
In the event acknowledgement cannot be obtained, record below the good faith effort to obtain the
acknowledgement and the reason the acknowledgement was not obtained.
Effort to obtain acknowledgement
In-person request
Request via mail (include copy of letter in medical record)
Request via email (include copy of sent email in medical record)
Other
Reason acknowledgement was not obtained
Patient refused to sign
Patient unable to sign
Patient did not return mail, email
Other
Employee Signature
Date
Notice of Privacy Practices with Separate AdcnaMedgement Form
NOTICE OF PRIVACY PRACTICES
Effective as of September 23, 2013
YOUR INFORMATION_ YOUR RIGHTS OUR RESPONSIBILITIES
This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
YOUR RIGHTS
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights haVe been violated
YOUR CHOICES
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
OUR USES AND DISCLOSURES
We may use and share your information as we:
• Treat you
▪
Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
•
•
•
•
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers' compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
YOUR RIGHTS
When it canesto your health information, you 'have certain rights
and some of our responsibilities to help you.
71
This section explains your rights
Get an electronic or paper copy of your medical record
•
•
You can ask to see or get an electronic or paper copy of your medical record and other health
information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your
request. We may charge a reasonable, cost-based fee.
Ask usto correct your medical record
•
•
You can ask us to correct health information about you that you think is incorrect or incomplete.
Ask us how to do this.
We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
•
•
You can ask us to contact you in a specific way (for example, home or office phone) or to send
mail to a different address.
We will say "yes" to all reasonable requests.
Ask usto limit what we use or share
•
•
You can ask us not to use or share certain health information for treatment, payment, or our
operations. We are not required to agree to your request, and we may say "no" if it would affect
your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say
"yes" unless a law requires us to chare that information.
Get a list of those with whom we've shared information
•
•
You can ask for a list (accounting) of the times we've shared your health information for six
years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care
operations, and certain other disclosures (such as any you asked us to make). We'll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one
within 12 months.
Get a copy of this privacy notice
•
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the
notice electronically. We will provide you with a paper copy promptly.
Choose sceneale to act for you
•
•
If you have given someone medical power of attorney or if someone is your legal guardian, that
person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rightsare violated
•
•
•
You can complain if you feel we have violated your rights by contacting the Practice in care of
the following officer: Privacy Officer, Lisa Wyatt, or you may call (504) 885-1039.
You can file a complaint with the U.S. Department of Health and Human Services Office for
Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201,
calling 1-877-696-6775, or visiting www.hhsgoviariprivacy/hipaatomplainte.
We will not retaliate against you for filing a complaint.
72
YOUR CHOICES
For certain health information, you can tell us your choices about what we share.
If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us what
you want us to do, and dwe will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference for exatrple if you are unconscious we nay go ahead
and share your information if we believe it is in your best interest. I* may also share your
information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USESAND DISCLOSURES
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Exarrple A doctor treating you for an iriury asks another doctor about your overall health
condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact
you when necessary.
Example: 1/% use health information about you to manage your treatment and se -vices
Bill for your services
We can use and share your health information to bill and get payment from health plans or other
entities.
Example. I* give information about you to your health insurance plan so it will pay for your
services
Haw else can we use cr share your health information?
We are allowed or required to share your information in other ways — usually in ways that contribute to
the public good, such as public health and research. We have to meet many conditions in the law before
we can share your information for these purposes. For more information see:
),N, - \ANA
goviocr/pro, acx /1 Lipaw understand giconsumers/index.hunl
-
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health or safety
Do research
We can use or share your information for health research.
73
L
Canply with the law
We will share information about you if state or federal laws require it, including -with the Department
of Health and Human Services if it wants to see that we're complying with federal privacy law.
Respond toorgan and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an
individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective
services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in
response to a subpoena.
OUR RESPONSIBILITIES
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or
security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can
in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if
you change your mind.
For more information see: W W W lihs.goviocriprivacv/hipathinderstanding/consumersinoticepplitml.
•
•
CHANGES TO THE TERM S OF THI S NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office, and on our web site (if applicable).
ADDITIONAL INFORMATION
If you have any questions regarding this notice or the subjects addressed in it, you may contact the
following officer: Privacy Officer, Lisa Wyatt, or you may call (504) 885-1039.
74