New Patient Form

Child's Information
Name
Date of Birth
MM slash DD slash YYYY
Sex Assigned at Birth
- Male
- Female
- Other
Gender Identification
- Male
- Female
- Other
Preferred Name / Nickname
Who referred you to our office?
School Name
Grade
Siblings
Preferred Language
- English
- Spanish
- Other
Email Address
Patient's Mailing Address
Street Address
City
State
Zipcode
Is the billing address the same as the mailing address?
- Yes
- No
How would you describe your child's temperament?
Billing Address
Street Address
City
State
Zipcode

Parent / Guardian Information #1
Name (First Middle and Last)
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Relation to Patient
- Mother
- Father
- Other
Occupation
Is your mailing address the same as the patient's?
- Yes
- No
Parent / Guardian's Mailing Address
Street Address
City
State
Zipcode
Home Phone (incl area code)
Mobile Phone (incl area code)
Work Phone (incl area code)
Marital Status
- Married
- Separated
- Divorced
- Single

Parent / Guardian Information #2
Name (First Middle Last)
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Relation to Patient
- Mother
- Father
- Other
Occupation
Is their mailing address the same as patient's?
- Yes
- No
Mailing Address
Street Address
City
State
Zipcode
Home Phone (incl area code)
Mobile Phone (incl area code)
Work Phone (incl area code)
Marital Status
- Married
- Separated
- Divorced
- Single

Dental Insurance Information
Subscriber's Name
Social Security Number (XXX-XX-XXXX)
Employer
Employer's Phone (incl. area code)
Insurance Company
Insurance Phone (incl. area code)
ID Number
Group Number

Emergency Contact Information
Emergency Contact
Phone Number (incl. area code)

Medication List / Pharmacy Information
Preferred Pharmacy
Pharmacy Phone Number (incl. area code)
Is your child taking any medications?
- Yes
- No
Has a doctor/dentist ever prescribed antibiotics for your child prior to a dental visit?
- Yes
- No
Has your child ever reacted adversely to any medications?
- Yes
- No
Is your child taking any birth control/hormone therapy replacement?
- Yes
- No
Please provide names of medications, dosages, frequency and reason for taking:
Please explain why antibiotics were prescribed:
Please list the medication(s) and reaction(s):
Please list name, dosage and frequency of birth control / hormone therapy replacements:
Please read the above and understand that the information provided in this form is true and accurate. A truthful health history will help ensure the best possible dental treatment. The information provided here will be used by the doctor and patient to inform any further discussion of the patient’s health prior to or during an appointment. By signing below, you also acknowledge that you will not hold the dentist the dental practice or any other member of the practice staff responsible for any action or lack of action because of errors or omissions that may have been made during the completion of this form.
*
- I agree the information provided in this form is correct to the best of my knowledge.
Parent/Guardian Signature*
Today's Date (mm/dd/yyyy)

Consent for Authorized Person(s)
Child's Full Name
Date of Birth (mm/dd/yyyy)
Parent / Legal Guardian's Name
I give permission to the person(s) listed below to accompany my child to the office of Santa Barbara Children's Dentistry for dental appointments. I also give permission to the person(s) listed below to make any necessary decisions regarding dental treatment for my child, including but not limited to:
- the consent for this authorized person(s) to sign any and all forms required to give the office permission to treat the dental needs of my child,
- the consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges) with this authorized person(s),
- the consent to the dental practice to discuss my child's future dental treatment needs (i.e. treatment plans),
- the consent for this authorized person(s) to sign my child's treatment plan once it has been presented by the dental team. I understand it does not obligate me to the treatment, only that the office has informed me or my representative of the dental needs of my child,
- the consent for this authorized person(s) to schedule future dental visits for my child.
I understand this consent will be valid for one year or until I rescind this agreement in writing.

Authorized Person(s):
Name of Authorized Person
Relationship to Child
Name of Authorized Person
Relationship to Child
Name of Authorized Person
Relationship to Child
Signature of Parent or Legal Guardian*
Today's Date (mm/dd/yyyy)

Treatment Consent
Please read this form carefully. If you do not understand any portion of this document, please alert our staff and we would be more than happy to explain further. By signing this document, I request and authorize the following dental treatment for my child by Dr. Hayley Cox and staff.
1. I understand it is the goal of this dental office to accomplish dental treatment by the use of warmth, friendliness, persuasion, humor, charm, gentleness and kindness and understanding. I understand that treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Behavior will be guided using praise, explanation and demonstration of procedures and instruments, using variable voice tone and loudness.
2. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided. During such disruptive behavior, it may be necessary for the assistant(s) and or doctor to hold the patient’s hands, stabilize the head and/or control leg movements for their safety. I also understand the routine use of “tooth pillows” (mouth props) may be necessary to be sure a child does not accidentally close their teeth while an instrument is in their mouth that could harm them. I also understand that mouth props are sometimes necessary if a child refuses to open their mouth.
3. I have had explained to me by the dentists and staff, and have had sufficient opportunity to discuss the patient’s dental condition/problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment plan, compared with alternative approaches and/or no treatment.
4. It is 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, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions.
5. I understand that during the course of the patient’s dental treatment, it may be necessary to change or add procedures because of a condition found while working on the teeth. I give permission to the dentist to make any changes and additions as necessary.
6. I confirm that I am a legal guardian to the child referenced. I also confirm that I have read and understand this form or it was read to me.
7. I understand that this consent shall remain in effect until terminated by me, and that I am free to withdraw my consent to treatment at any time.
Name of Patient
Parent/Guardian Name
Parent/Guardian Signature*
Today's Date (mm/dd/yyyy)*

Appointment Agreement
Our goal is to provide treatment in a timely manner with as few visits as necessary. In order to provide the best services to our patients, we require at least a 48-hour notice of cancellation or change to your child's appointment. We understand that unforeseen circumstances may arise and will make every effort on our end to be as accommodating as possible. A $50 fee may be assessed for multiple missed appointments, short notice, or cancelled appointments. Multiple failed appointments may result in dismissal from our office.

You will receive two letters for missed appointments without proper notification given. After the second letter, you will be placed on a "same-day appointment" list. On a day that you feel it is convenient to bring your child in, call our office and, if time allows, we will place them in our schedule.

Parents/patients that are running late are asked to call the office as soon as possible to check with the front office team to determine if the office will still be able to keep their appointment. Cancellations left on our voicemail are not accepted and will not be considered cancelled. Please call during regular business hours and speak with a team member if you need to make a change.

In consideration of other patients, your child's appointment may be rescheduled if you are more than 10 minutes late for your scheduled appointment time.

School holidays, as well as before and after school hours are our most popular appointment times. Appointments canceled with less than 2 business days' notice that are scheduled on a school holiday, before or after school time will not be rescheduled on another school holiday, before or after school appointment time.

We greatly appreciate your cooperation in helping us provide excellent care to your family. Please sign below that you have read and acknowledge the above information provided to you.
Name of Patient
Parent/Guardian Name
Parent/Guardian Signature*
Today's Date (mm/dd/yyyy)*

Financial Agreement
We are pleased to welcome you to our practice. Our desire is to provide your child with the highest quality dental care in a caring and enjoyable atmosphere. It is our policy to make definitive financial arrangements with you before any treatment begins. Below is an explanation of our payment procedures. If you have any questions, please do not hesitate to ask.
1. Full Payment for services is due at the time services are rendered. We accept cash, checks, and credit cards.
2. As a courtesy, we will file your insurance claims for you.
3. Our office will file your insurance claim a maximum of two times per appointment.
4. If the claim is not paid by your insurance carrier within sixty days, you will be responsible for the full balance and further insurance appeal becomes your responsibility. We will be happy to provide you with a claim form so that you can follow up on your insurance claims personally.
5. Any balances on your account from previous visits are expected to be taken care of within 30 days of receiving your statement.
6. A copy of your insurance card is requested at the time of service. If this is not provided, you may be asked to make a full payment of all fees for the services rendered that day.
7. If insurance benefits are assigned to the doctor, you will be responsible for paying your deductible and estimated portions at the time of service. You are responsible for paying all charges not covered by your insurance company. If it is an out of network insurance, you are responsible for the fees considered above your insurance company's usual and customary fee schedule. Our office cannot guarantee a quote prior to the time of service, even if the quote has been pre-authorized by the insurance company.
8. Your insurance benefits are a contract between you and your employer. The amount of coverage you will receive will depend on the quality of the plan purchased by your employer, not the fees of the doctor.
9. Your insurance plan may also have exclusions or limitations on a specific procedure frequency. Downgrades are also common and can result in very low coverage and are not always disclosed to our staff when we verify benefits. If the plan contains one or more of these clauses, you will still be responsible for any portion insurance does not cover.
10. The office cannot carry balances longer than 90 days, regardless if the insurance payment is still pending. A $20.00 monthly re-billing charge will be added to your account if it is not paid within 60 days.
11. After 90 days, we will inform you of the delinquent account by letter and if no action is taken to clear the account, this office will be required to employ a collection service to collect payment. We reserve the right to refuse appointments with delinquent accounts. In the event that your account is sent to a collection agency, you will be responsible for all costs and fees, including reasonable attorney's fees incurred.
12. There will be a $35.00 service charge for all returned checks.
13. Should there be a divorce, custody, or separation arrangement, the parent or guardian who signs this financial agreement is ultimately responsible for any balances owed to our practice.
I have read, understand, and accept the above financial agreement and agree to the terms set forth regarding payment.
Name of Patient
Name of Responsible Party
Responsible Party Signature*
Relationship to Patient*

Patient Photo Release Form
I hereby authorize Santa Barbara Children's Dentistry or any of their assignees to take photographs, slides, and/or videos of my child. I understand the photographs, slides, and videos will be used as a record of my child's care, may be used for communication with other health care professionals, and advertising purposes (social media and/or marketing). I further understand that if the photographs, slides, and videos are used in any publication or as a part of a demonstration, my child's identifying information (first name only) may be used unless stated differently below. I understand that information disclosed under this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. By signing this Agreement, I waive the right to inspect or approve the finished product. I do not expect compensation, financial or otherwise, for the use of these photographs, slides or videos, and waive any right to royalties or other compensation arising or related to the use of the photograph, slides, or video.

If I wish to revoke this consent, I may do so in writing.
I agree that my child’s photographs, slides, or videos can be used in any of the above described situations*
- Yes
- No
I agree to have my child’s photos, slides or videos used, but do not agree that my child’s name may be used.*
- Yes
- No
Patient's Name
Parent / Guardian's Name
Parent / Guardian Signature*
Today's Date (mm/dd/yyyy)*

HIPAA Notice of Privacy Practices
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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your dentist, our staff, and others outside of our office that are involved in your care and treatment for the purpose of providing healthcare services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
2. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your dental health care and any related services. This includes the coordination or management of your healthcare with a third party. For example, your protected health information may be provided to a dentist to whom you have been referred to ensure that they have the necessary information to diagnose or treat you.
3. Payment: Your protected health information will be used as needed, to obtain insurance payment for your dental care services.
4. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to dentists for the purpose of reaching comprehensive treatment planning. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health information, as necessary, to contact you remind you of your appointment or send a postcard to remind you to schedule an appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate and determine our compliance with the requirements of Section 164.500

Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

You may revoke this authorization at any time in writing except to the extent that your dentist or the dental practice has acted in reliance on the use or disclosure indicated in the authorization.

Your Rights:

Following is a statement of your rights with respect to your protected health information.
1. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
2. You have the right to request a restriction of your protected health information. This means you may ask us to not use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
  
  Your dentist is not required to agree to a restriction that you may request. If your dentist believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
3. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us upon request even if you have agreed to accept this notice alternatively; i.e electronically.
4. You may have the right to have your dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
5. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints:

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against your for filing a complaint.

This notice was published and becomes effective on/or before June 1, 2020

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at (805) 421-4469

Your signature below is only abacknowledgement that you have received this Notice of our Privacy Practices.
Patient's Name
Parent / Guardian's Name
Parent / Guardian Signature*
Today's Date (mm/dd/yyyy)*

Step 1 of 15

Child's Information

Patient's Mailing Address

Billing Address

Parent / Guardian Information #1

Parent / Guardian's Mailing Address

Parent / Guardian Information #2

Mailing Address

Dental Insurance Information

Emergency Contact Information

Dental Information

Medical Information

Allergies

Medical Conditions

Medication List / Pharmacy Information

Consent for Authorized Person(s)

Authorized Person(s):

Treatment Consent

Appointment Agreement

Financial Agreement

Patient Photo Release Form

HIPAA Notice of Privacy Practices

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