Patient Forms Gregory D. Evans. DDS PC 3221 Eastbrook Drive; Fort Collins, CO 80525 ~ Phone: (970) 407-1020 Fax: (970) 226-8238 Health History We believe that to best serve your child’s dental health, we must understand your child in the larger context of his/her social and medical history.Please help us by thoughtfully answering the following questions. Please note that all health histories are held in strict confidence among our team. Complete both pages of the form. Birth Date: Gender: Male Female State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Is the child under care for any medical conditions? YesNoUnsure Immunizations up to date? YesNoUnsure Has child ever spent the night in a hospital? YesNo Allergies: Latex YesNo Metal YesNo Foods: Medications: Reaction to above allergies: Has your child ever had or been diagnosed with any of the following: First Group YesNo Anemia YesNo Blood Disease YesNo Blood Transfusions YesNo Bruises Easily YesNo Hemophilia YesNo Sickle Cell Trait or Disease Second Group YesNo Aids/HIV YesNo Cancer or Malignancy YesNo Chronic Illness YesNo Diabetes YesNo Epilepsy YesNo Hepatitis/Liver disease YesNo Kidney Disease YesNo Transplant Third Group YesNo Asthma YesNo Respiratory Problems YesNo Disease/RSV YesNo Heart Surgery YesNo Heart Murmur/Defect YesNo High Blood Pressure YesNo Rheumatic Fever Fourth Group YesNo Birth Defects YesNo Child Abuse YesNo Concussion YesNo Growth Problems YesNo Premature Birth YesNo Hepatitis/Liver disease YesNo Surgery YesNo Syndrome Fifth Group YesNo Arthritis YesNo Bone/Joint Problem TMJ YesNo Headaches YesNo Metabolic Disorder YesNo Muscle Disorder Sixth Group YesNo Brain Injury YesNo Developmental Delays YesNo Hearing and/or Speech Problems YesNo Hyperactivity/ADD/ADHD YesNo Neurological Disorder Please answer based upon your child’s age: Feeding History (ages 0 – 2.5 years): My child was: BreastBottleCombination Bottle introduced at age: Bottle Use: currently usedDiscontinued Oral Hygiene (ages 0 – 9 years): Have your ever received instruction on how to clean your child’s teeth? YesNo My child brushes times a day.An adult SupervisesHelpsBrushesNone per day. My child has their teeth flossed Every DayOccasionallyNot Currently. Fluoride Use (all ages): When did your child begin to use toothpaste? How often / day? Who applies the toothpaste to the brush? ChildAdult My child DoesDidDid not receive supplemental fluoride drops or tablets. Our primary water supply DoesDoes notUnsure contain fluoride. Habits (all ages): My child DoesDoes not suck a ThumbFingerPacifier. When, where and how often? Stopped at age: Dental History (all ages): Is there any history in your family of any: Malocclusions (bad bites)Missing TeethExtra Teethother Do you think there is anything wrong with your child’s teeth? Has your child ever had a Space Maintainer,RetainerBracesor any other orthodontic treatment? What is the primary reason for today’s visit? Family History (all ages): Do mother and father live together? YesNo Is your child adopted? YesNo Please explain any recent family status changes (divorce, separation, death, etc.), and note when your child experienced this change: Is your child receiving any therapy or extra help in any area? Referral (all ages): How did you hear about our office? (List name or media responsible for referral): CONSENT It is necessary, because your child is a minor, for permission to be obtained from a parent/legal guardian before necessary treatment is performed. The signature of the parent/guardian below authorizes the completion of all agreed upon dental treatment and the use of those methods appropriate thereto. This consent shall remain in full force and effect until cancelled by either party. Furthermore, the undersigned agrees to be responsible for any bill incurred on this child for dental treatment, regardless of insurance coverage. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form. Also, the undersigned consents to the use of agreed upon x-rays, clinical photographs and other diagnostic aids used for professional educational purposes. My signature also indicates that I give permission to use my child’s photograph in promotional or educational materials excluding advertisements. The subject of the photograph will not be identified by name, nor will any financial reimbursement be paid for the photograph. I fully understand this consent and have no further questions. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy. GREGORY D. EVANS, DDS PC We find that our clients appreciate knowing in advance what is expected of them financially and what terms and conditions are available. If you have any questions, please direct them to one of our Financial Administrators.As a condition of treatment by this office, all fees are due and payable at the time of service. We gladly accept cash, personal checks, and most major credit cards for payment of your account. For your convenience, we also work with Care Credit. As a courtesy to you, we will submit your claim for you if you have insurance. Your insurance policy is an agreement between you and your insurance company. Our relationship is with you, not your insurance company. Therefore, all charges are ultimately your responsibility, regardless of your insurance status. You are responsible for the total charges or any difference remaining following payment by your insurance company. We will estimate as closely as possible your coverage. If your insurance has not made payment or you feel that your insurance company has not made adequate payment on your account, you must contact them first to discuss this matter.Your insurance company is required by the Colorado Insurance Commissioner to process, pay or reject all insurance claims within 30 days. We guarantee accurate filing based on the information that you provide to us. On day 31, if your insurance company has not reimbursed our office, we will investigate the delay as a courtesy. If needed, we will resubmit your insurance claim one time for you. We will notify you of your insurance company response and the responsibility of the balance will revert to you.Payment is expected on date of service. We will try to accurately estimate your patient portion which is due after insurance. As a courtesy, we would be happy to send a preLdetermination to assist with accurate patient portions. In different circumstances, if the patient portion was not collected on date of service, payment is expected within 30 days of insurance payment. We will send you a statement, and payment is due upon receipt. We will begin to charge a late fee of $5.00 per month on accounts that have remaining balances over 90 days. For your convenience you may now pay your bill online at biggrinswithdrgreg.com and click “Pay My Bill”.In consideration of the professional services rendered to my child, I agree to accept responsibility for the payment of such services; and I agree to pay all legal costs including collection fees and attorney fees if I fail to pay my account. I grant you, or your assigned, to telephone me at home or at my work to discuss matters related to this form. I have read and agree to the above conditions of treatment. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy. 1. Tell Us About Your Child Child's Name: Same as above Date of Birth: Siblings: Date of Birth: Date of Birth: Date of Birth: Child’s Main Phone #: Child’s Home Address: 4. Who is Accompanying the Child Today? Do you have legal custody of this child?YesNo 2. Mother’s Information MotherStepmotherGuardian Date of Birth: 5. Primary Dental Insurance Subscriber’s Date of Birth: 3. Father’s Information FatherStepfatherGuardian Date of Birth: Do mother and father live together?YesNo 6. Do you have secondary dental insurance? YesNo If yes, you will be asked to provide us with this additional information. We are happy to file your insurance claims as a courtesy to you. Thank you for providing accurate and updated information as it will expedite timeliness on your account. Notice of Patient Health Insurance Portability and Accountability Act (HIPAA) Date of Birth: I have read or had the opportunity to read practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice’s legal duties with respect to my protected health information. The Notice includes: A statement that this practice is required by law to maintain the privacy of protected health information. A statement that this practice is required to abide by the terms of the notice currently in effect. Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment and health care operations. A description of each of the other purposes for which this practices I permitted or required. A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization. My individual rights with respect to protect health information and a brief description of how I may exercise these rights in relation to: The right to complain to this practice and the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such complaint. The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction. The right to receive confidential communications of protected health information. The right to inspect and copy protected health information. The right to amend protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request. This practice reserves all rights to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices on request. Cancellation Policy Big Grins is proud to be an on time dental practice. When we schedule an appointment for your child, two events occur. 1. We will hold that appointment time for your child in our appointment book and 2. We trust that you will arrive on time for that appointment. If you are late for an appointment, we will try to do our best to fit you in our schedule. However, it may be necessary for us to reschedule your appointment. Please note that there will be a $25 fee per child for cancellations made with less than a 24 hours notice. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy. Today's Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.