New Patient Registration
  Press the submit button at the end of the page to send the information to us. Please fill out separate forms for each child.
Patient Registration
Child's Information
 
Child First Name
Child Last Name
Nickname
male female
Child Birthday
Mailing Address
City, State, Zip
If your mailing address is a PO Box, please include your home address.
 
Home address
City, State, Zip
Child School/Nursery/Preschool
Grade
Emergency Contact (other than parent)
Relationship
Phone
How did you hear about us?
Which best decribes your child's personality?
normal shy nervous difficult
 
Parent Information
Father's Information
information not available deceased
Father First Name
Father Last Name
Father Social Security Number (SSN)
Father Date of Birth
Father Address
City, State Zip
Home phone number
Work phone number
Cell phone/pager number
Occupation
Employer
e-mail
   
Mother's Information
information not available deceased
Mother First Name
Mother Last Name
Mother Social Security Number (SSN)
Mother date of birth
Mother Address
City, State Zip
Home phone number
Work phone number
Cell phone/pager number
Occupation
Employer
e-mail
   
Parent marital status
married separated divorced other
If parents are not married, who does the child live with?
Who is the child's legal guardian?
   
Insurance Information
Primary Dental Insurance
No dental insurance
Insurance Company
Phone number
Group number
Subscriber/Policy Holder
Subscriber Identification (often SSN)
Subscriber's DOB
   
Secondary Dental Insurance
No secondary insurance
Insurance Company
Phone number
Group number
Subscriber/Policy Holder
Subscriber Identification (often SSN)
Subscriber's DOB
   
Child Health Summary
Your child's medical history may have an impact on dental care. It is very important to answer all questions truthfully and to the best of your knowledge- this will enable us to plan for your child's individual treatment and to avoid unnecessary personal health risks. All information is kept strictly confidential.
   
Name of your child's physician
Office/Clinic name
Office/Clinic Phone number
Date of last medical exam
Reason for medical visit
 
Describe illness or medication taken during this pregnanacy
Has your child ever been hospitalized?
no yes
Date of hospitalization(s)
What for?
Has your child ever had surgery?
no yes
Date of surgery(ies)
What for?
Has your child ever had a blood transfusion?
no yes
   
Immunization status
up to date
not up to date
prefer not to immunize
Immunizations received
 
polio DPT MMR Hepatitis
chicken pox
Is your child taking any medication (over the counter or prescription)?
no yes
Name of medication
Dose
What for?
Is your child taking any natural herbs/remedies/ tinctures/supplements?
no yes
Name of herbs/remedies/tinctures/supplements and why they are being taken
   
Does your child have/had any of the following?
None of these
Asthma
Allergy
Sinus Problems
Respiratory/Lung Disease
Learning disability
Developmental Delay
Behavior Problems
Autism/PDD
ADHD/ADD
Hearing Impairment
Earaches/Ear tubes
Speech difficulties
Vision impairment
Eczema
Heart Murmur
Congenital Heart Defect
Kidney disease
Liver disease
Diabetes
Thyroid problem
Headaches
Hydrocephalus
CSF shunt
Epilepsy/Seizure Disorder
Bladder Problems
Anemia
Bleeding Disorder
HIV+/AIDS
Ulcer
Cancer
Chemotherapy
Radiation Therapy
Indwelling Catheter
Cerebral Palsy
Syndrome
Premature birth
Please describe checked conditions:
Have you been told that your child requires antibiotics prior to dental treatment?
no yes
Name of physician who told you this
 
medication/drugs?
no yes
latex?
no yes
foods?
no yes
Please describe allergy(ies)
Is you child allergic to:
 
   
Teenage Girls Only
 
Some antibiotics may reduce the effectiveness of birth control pills. Some medications may affect an unborn fetus.
Are you pregnant?
no yes
Are you taking birth control pills?
no yes
Do you get a birth control shot?
no yes
   
Patient Dental History
Is this your child's first dental visit?
no yes
If no, previous dentist?
Would you like us to request the records from the other office?
no yes
Previous dentist phone number
Date of last dental exam?
Is there any particular situation you would like examined?
Has your child complained of any dental problems?
Any unhappy dental/medical experiences?
no yes
Any injuries to the mouth, teeth or head?
no yes
Comments
 
What are your child's sources of fluoride?
water toothpaste
supplement rinse
gel none
family prefers no fluoride
 
Mouth habits
thumbsucking finger sucking
nail biting pacifier
grinding sucking on lip
baby bottle nursing
mouth breathing tobacco use
none  
Does your family see a dentist for regular care?
no yes
Is there anything else we should know?
Would you care to speak privately to Dr. Woo?
no yes
 
Name of person filling out this form
Date
 
Note: Below are copies of office policies and authorizations for care. Only a legal guardian may sign for consent for care. You will be asked to sign these forms when you arrive at the office.

Authorizations

Authorization to Release Information Children's Dentistry of Issaquah is hereby authorized to release any medical or incidental information that may be necessary for medical care or in processing insurance.

Authorization for Care I am legally authorized to obtain medical services for my child, __________________________. I, __________________________________, the parent/legal guardian authorize and consent to routine and emergency dental treatment for my child when deemed necessary by qualified dental personnel. This authorization will be in effect until revoked in writing by me.

 

Financial Policy

Patients with Insurance As a courtesy, Children's Dentistry of Issaquah will make every effort to contact your insurance company to determine your child's eligibility and benefit status. The information received is a guideline and is not a guarantee of payment. At the time of treatment, you are required to pay the difference between the treatment fee and the estimated insurance benefit. If your insurance company requires a pre-determination, Children's Dentistry of Issaquah will submit all necessary documents and notify you when a written copy is received. You should be aware that a pre-determination of benefits, oral or written, does not guarantee insurance coverage. Your insurance is a contract between you, your employer and the insurance company. It is your responsibility to inform us of any changes. We reserve the right not to submit/resubmit claims for treatment if updated information is not provided at the time of service. Ultimately, you are responsible for any unpaid balance. Patients with NO insurance Patients without dental insurance are asked to pay the entire treatment fee at the time of services. Payment Options To assist you, we offer the following options for payment: 1. cash/check 2. Debit/Credit card (Visa/Mastercard).

I acknowledge and agree to all the policies above.

 

Privacy Policy

We keep a record of the health care services we provide for your child. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your child's record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your child's record or get more information about it by contacting our office. Our Notice of Privacy Practices describes in more detail how your child's health information may be used and disclosed, and how you can access your child's information.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

 

Thank you for providing your child's information. Please press submit once.

 

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Illustrations by Clinton Hobart.
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