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Welcome to Shining Dental PLLC

Patient Information


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  • Male
  • Female
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Address Child Resides

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How did you hear about us?

Parental Information


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  • Mother
  • Father
  • Step Mother
  • Step Father
  • Legal Guardian

Home Address (if different from child)

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This field is required and must be filled with valid email address!
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  • Father
  • Mother
  • Step Mother
  • Step Father
  • Legal Guardian

Home Address (if different from child)

If this field is required, it must be filled with valid phone number (10 digits number)!
If this field is required, it must be filled with valid phone number (10 digits number)!

Dental Insurance Information


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Authorization for a Babysitter/Grandparent/Non parent/Family Member over 18 years old to bring my child in for treatment:

If parent/ legal guardian is unable to bring the child(ren) for treatment, I,

,the
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  • Mother
  • Father
  • Legal Guardian
of

, authorize the adult(s) listed below to accompany my child(ren) and to provide consent for all treatments including, but not limited to exams, cleanings, x-rays, fillings, endodontic treatment, crowns, orthodontic treatment. A different consent for papoose/ medical immobilization and extractions and nitrous oxide should be signed by a legal guardian and or verbal consent as well. The authorization will remain in effect until such time as I give notice of its termination.

This field should be filled with valid phone number (10 digits number)!
This field should be filled with valid phone number (10 digits number)!

MEDICAL HISTORY QUESTIONNAIRE


Name of Child:

Name of legal guardian (Parent):

Date of Birth:

Sex:

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This field is required and must be filled with valid phone number (10 digits number)!
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For the following questions, please check "Yes" or "No", whichever applies. Your answers are for our records only and will be kept confidential. Please note that during your initial visit you will be asked some additional questions about your responses to this questionnaire.

  • Is your child in good health?
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  • Has there been any change in their health within the past year?
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  • Have they ever been hospitalized or had surgery?
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  • Are they taking any medicine(s) including non-prescription medicine?
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  • Are their immunizations up to date?
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  • Has your child had an allergic reaction to medicine or foods?
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  • Please check any of the following that your child has had:

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  • Please describe any other medical problems not listed above

Please check this box to proceed.

DENTAL HISTORY QUESTIONNAIRE


Patient Name:

Date of Birth:

  • Was your child:
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  • Does/Did your child sleep with a bottle?
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  • If currently bottle feeding, what is fed from the bottle?
    This field is required!
  • How often does your child eat snacks?
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  • Has your child ever been to the dentist?
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    and

  • Has your child experienced unfavorable reaction from previous dental care?
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  • Who brushes your child’s teeth?

    This field is required!
  • How many times per day does your child brush?

    This field is required!
  • Does your child floss regularly?
    This field is required!
  • Has your child ever injured his/her teeth or gums?
    This field is required!
  • Does your child’s jaw make noise and is pain associated with the sounds?
    This field is required!
  • Does your child suck a finger, thumb, or pacifier?
    This field is required!
  • Does your child grind his/her teeth?
    This field is required!
  • Does your child breath by mouth and snore when sleep?
    This field is required!
  • Does your child have any injuries to the teeth, lip. Mouth, chin or face?
    This field is required!
  • Is there a family history of missing or extra teeth?
    This field is required!
  • Check if your child is having problems with any of the following:

    This field is required!

Fluoride History

  • Is your home water supply fluoridated?
    This field is required!
  • Does your child use fluoride toothpaste?
    This field is required!
  • Do you give your child any other type of fluoride, such as rinses or vitamins?
    This field is required!

Office Policies


Appointments

Please arrive 5 minutes before your child’s reserved appointment. If you are unable to keep your child’s dental appointment, please give us at least 48 hours notice, if at all possible. We would happy to reschedule your appointment if necessary. We reserve the right to charge for missed no reason appointments.

If 3 times no show or broken the appoint with no reason, we reserve the right to dismiss the patient from the clinic.

Financial Policies

Payment is due at the time services are rendered.

It’s patient’s responsibilities for any remaining balance if anything denied by the dental insurance.

For out-of-network patients or patients without dental insurance, we require payment in full on day of service.

Payment Methods

We only accept cash

Photos and Videos

Please inform us before you take any photos/ videos, so that the staff does not appear in any recordings/ photos without their consent. It is important for us to ensure the protection of the privacy of other patients in the office.

Please do not record or take pictures during the procedure.

Please check this box to proceed.

PEDIATRIC PATIENT INFORMED CONSENT FOR PATIENT MANAGEMENT TECHNIQUES


ALL IN GOOD INTENTION

It is our intent that all professional care delivered in our dental office shall be of the best possible quality we can provide for each child. The entire focus is on your child, relating to them, fostering good dental health habits and instilling a healthy, positive attitude toward dentistry for life.


All efforts will be made to obtain the cooperation of pediatric dental patients via a path of warmth, friendliness, persuasion, humor, charm, gentleness, kindness, and understanding. In some cases, further behavior management techniques discussed below are deemed necessary according to the guideline of American Academy of Pediatric Dentistry (AAPD). These behavior management techniques are used by pediatric dentists to gain the cooperation of child patients to eliminate disruptive behavior or prevent patients from causing injury to themselves due to uncontrollable movements. These techniques are not a form of punishment and are in no way used as a form of punishment. These techniques are simply used only when and, if necessary, to complete a dental procedure in the safest manner possible.


Please read this form carefully & ask about anything you do not understand. Please initial to identify you understand the techniques we use.


PEDIATRIC DENTISTRY BEHAVIOR MANAGEMENT TECHNIQUES

  1. Tell-Show-Do: The dentist or assistant explains to the child what is to be done using simple words and then shows the child what is to be done by demonstrating with instruments on a model or the child's or dentist's finger. Then the procedure is performed in the child's mouth as described.
  2. Positive reinforcement: This technique rewards the child who displays any behavior which is desirable. Rewards include compliments, praise, pat on the back, a hug, or a prize.
  3. Voice control: Is a controlled alteration of voice volume, tone, or pace to influence and direct the patient's behavior.
  4. Distraction: Sometimes it is necessary to distract your child from an unpleasant sensation by focusing his/her thoughts on something other than what is being done.
  5. Mouth props/Rubber dams: A mouth prop or “tooth pillow” as we call it is used to help support your child in keeping his/her mouth open during an operative procedure (filling, etc) This allows him/her to relax and not worry about consciously keeping his/her mouth open for the procedure. A rubber dam is a "raincoat" placed on the area of work to isolate the working teeth and prevent any debris from being swallowed.
  6. Immobilization by the dentist: The dentist controls the child from movement by gently holding down the child's hands or upper body, stabilizing the child's head between the dentist's arm and body.
  7. Immobilization by the assistant/ Papoose board: The assistant and/ or papoose board controls the child from movement by gently holding the child's hands, stabilizing the head, and/or controlling leg movements.
  8. Relaxation Gas: Nitrous oxide and oxygen (laughing gas) may be administered to relax the child and to raise his/her pain threshold. This allows the child to sit in chair longer and allows for dental work to be done without the child labeling something as painful. The child is not "put to sleep" and does not become unconscious, only relaxed.
  9. Conscious Sedation is recommended for mildly apprehensive and very young children. The majority of children respond very well for dental treatment. For various reasons, some children may be apprehensive about dental treatment and may require some form of conscious sedation to allow treatment.

ACKNOWLEDGMENT OF RECEIPT OF INFORMATION

  1. The listed pediatric dentistry management techniques have been explained to me.
  2. I am clear and understand that none of the above techniques are used in any way as punishment. These procedures are standard of care in the pediatric dental community and are merely used only if necessary to provide the best dental care.
  3. I have been encouraged to ask questions and all questions about the patient management techniques described have been answered in a satisfactory manner.
  4. I hereby acknowledge that I have read and understand this consent.
  5. I acknowledge that I have not been coerced/ forced to sign this consent and that I have been given the alternative to withdraw from it.
  6. I hereby authorize and direct Dr. Ye assisted by other dentists and/or dental assistants of her choice, to utilize, if required, the necessary patient management techniques to assist in the provision of the required dental treatment for my child (or legal ward).

  7. I understand that this consent shall remain in effect until terminated by me.
Please check this box to proceed.

Pediatric Patient General Consent


Dear Parent or legal guardian,

Since my child is a minor, it becomes necessary that a signed permission is obtained from a parent or legal guardian before any dental services can be started and accomplished by doctors associated with Shining Dental.

Authorization is hereby granted to do the following procedures including but not limited to -an examination, take X-rays, clean teeth, give fluoride treatment, and provide oral hygiene instructions if deemed necessary. Following a consultation, authorization is hereby granted to administer any treatment, anesthetics, extractions, and perform such operations or otherwise treat my child as it may be deemed necessary and or advisable. I also give permission to provide my child with emergency care if needed.

Its unusual for any of the following risks or complications to occur. These risks or complications. Include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, temporary or permanent numbness, and allergic reactions.

I understand that during the course of the patient’s dental treatment, something unexpected may arise that may necessitate procedures in addition to or different from those listed on the patient’s treatment plan and that I will be consulted prior to initiation of treatment procedures not listed. I am aware that the practice of dentistry is no an exact science and acknowledge that no guarantees have been made to me concerning the results of the dental treatment that the patient receives in the office.

I further understand that this consent will remain in effect until such time that I choose to terminate it.

I understand that I accept responsibility for payment of services rendered.

I certify the truth of the information given. I also authorize the release of pertinent information to those persons requiring it for treatment of my child or for the purpose of payment of the account or credit references.

Please check this box to proceed.

HIPAA PRIVACY NOTICE


This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

INTRODUCTION:
Shining Dental PLLC. understands that your medical information is private and confidential. Further we are required by law to maintain the privacy of "protected health information". "Protected Health information" includes any individually. Identifiable information that we obtain from you or others that relate to you pass, or future physical or mental health, the health care you received, or payment for your health care.

As required by law, this notice provides you with the information about your rights and our legal duties and privacy practices with respect to the privacy of protected health information. This notice also discusses the used and disclosures we will make of your protected health information. We must comply with the provisions of this notice as currently in effect. Although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain.

PERMITTED USED AND DISCLOSURES:
We can use or disclose your protected health information for purposes of treatment, payment and health care operations. For each of these categories of use and disclosure, we have provided a description and an example below. However, not every particular use of disclosure in every category will be listed.

TREATMENT means the provisions, coordination or management of your health care; including consultations between health care providers regarding your care and referrals for health care from one health care provider to another.

PAYMENT means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, determination of eligibility and coverage and utilization review activities. For example, prior to providing health care services, we may need to. provide information to your Third-Party Payer about your medical condition to determine whether the proposed course of treatment will be covered. When we subsequently bill the Third Party Payer for the services rendered to you, we can provide the Third Party Payer with information regarding your care if necessary to obtain payment. Federal or State lay may require us to obtain a written release for you prior to disclosing certain specially protected health information for payment purposed, and we will ask you to sign a release when necessary under applicable law.

HEALTH CARE OPERATIONS means the support functions of our practice related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician review, compliance programs, audits, business planning, development, management and administrative activities. For example, we may use your protected health information to evaluate the performance of our staff when caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed and whether certain new treatments are effective. In addition, we may remove .information that identifies you from your patient information so that others can use the de-identified information to study health care and health delivery without learning who you are.

OTHER USES AND DISCLOSURES OF PROTECTED INFORMATION
In addition to using and disclosing your information for treatment, payment and health care operations, we may use your protected health information in the following ways:

If a phone call is made to my home, I give permission to leave a message on my answering machine. In addition, I give permission to disclose information to the following person(s):

Please check this box to proceed.

AUTHORIZATION AND CONSENT


I, certify that I am the parent, legal guardian, or personal representative of (name of patient) and there are no court orders now in effect that prohibit me from signing this consent. As this child’s parent, legal guardian, or personal representative, acknowledge that the information I have given is complete and correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform the office of any changes in my child’s medical status. I understand that misrepresenting or withholding medical/dental information can be harmful to my child during dental treatment.

I do hereby authorize the dental staff to perform an oral examination (including any necessary x-rays and photos) and after explanation, any and all treatment for the above named child. I consent to such methods, drugs/anesthetics, and agents that may be indicated and deemed advisable by the doctor in connection with my child’s dental care, whether or not I am present when the treatment is rendered.

I authorize my insurance company to pay Shining Dental PLLC all insurance benefits otherwise payable to me for service rendered. I also authorize the use of this signature on my behalf or my dependents, whether or not it is covered by my insurance company, and that all payments are due when services are rendered.

I hereby authorize Shining Dental PLLC to release any information, including the diagnosis and the record of any treatment or examination, rendered to my child during the period of such dental care to third party payors and /or other health practitioners.

This consent shall remain in full force and in effect until cancelled in writing.

Please check this box to proceed.

By signing(with mouse or touch) on the signature pad below, I (patient's parent or legal guardian) acknowledge that I have read, understood and agree to the entire contents including all the policies, notices and consents of this patient form.

Parent/Leagl Guardian Signature

Parent/Leagl Guardian Printed Name: Date: //