New Patient Registration Form

EastBayPediatricDental.com New Patient Registration Form

Patient Information

Gender:
Is child adopted?
Does child know they are adopted?
How did you hear about our practice?
Have we treated any other family members?

Dental History

Is this your child's first visit to the dentist?
Were X-rays taken?
Does your child brush their teeth?
Does your child brush with adult supervision?
Does your child floss?
Does your child take a fluoride supplement?
Is your water fluoridated?
Does your child use a fluoride toothpaste?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently, or has your child ever, had a history of:

Medical History

Is your child currently being treated by a pediatrician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Check if your child has or has ever had any of the following:

Parent / Guardian Information (Self)

Marital Status:
Relation to Patient:

Financial Policy: Without the SSN of the responsible party completing this form, the patient will be required to pay for all services in full at the time of the visit. We will provide you with completed insurance forms to be mailed in by you, directing all claim reimbursement to be mailed directly to the policyholder.

I acknowledge and understand the above policy:
Phone Type
Phone Type

Insurance Information

Dental insurance coverage is provided through:

Parent / Guardian Information (Spouse/Co-Parent)

Marital Status:
Relation to Patient:
Phone Type
Phone Type

Dental Insurance Information

*Please note, most companies provide medical and dental insurance through different insurance companies; please be sure to provide information pertaining to your dental insurance. Necessary information for us to submit a complete claim on your behalf is: Primary Policy Holder Name, Address, Birthday, SSN or Member ID, Insurance Company Name, and Employer (if applicable). We can usually use this information to determine your group number if you need assistance.

Dental insurance coverage is provided through:

Emergency Contact / Additional Caregiver Information

Person, other than parent or guardian, that you allow us to release appointment or medically-related information to regarding your child.

Authorization

The permission of a parent or guardian is necessary for dental treatment of a minor. I give the permission to use such measures as deemed necessary in Dr. Patrick C. Creevan's professional judgement to render the best dental treatment for my child. I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's health status or contact information. I have also received a copy of "The Facts About Fillings" as required by law (available for review and/or download on eastbaypediatricdental.com).

Financial Agreement

Patients with dental insurance must provide accurate and complete insurance information so we may assist you in filing your claim promptly. If you have provided the office with your SSN, you will be required to pay only the patient portion as dictated by your insurance plan on the day of dental treatment. If you prefer not to provide your SSN you will be required to pay for all services in full on the day of dental treatment. The office will assist you in filing your insurance claim by providing you with a completed claim form for you to mail. This form will direct all insurance reimbursement payments to be sent directly to you.

I hereby authorize the dentist to release any information including diagnosis and records to the third party payor and/or other health care practitioners. I authorize and request my insurance to pay directly to the above named dentist, otherwise payable to me but not to exceed the charges shown on the claim. I understand I am financially responsible for any charges not covered by my insurance or by this authorization, I realize that the failure to keep this account current may result in the dentist unable to provide additional dental services except for dental emergencies, or where there is a prepayment for additional services; and where appropriate, a credit bureau report may be obtained.

When insurance coverage is not provided for the patient, payment in full is expected at the time of dental service. When this is not possible, financial arrangements must be made in advance.

As a cash-pay family you may opt to receive a statement of your account balance, payable within 30 days of services rendered, however, the social security number of the party completing this form must be provided. This policy may be subject to change depending on timely account payment.

A $75 Missed Appointment fee may be charged to your account for appointments that missed or cancelled with less than 24 hours.

I realize that the failure to keep this account current may result in the dentist being unable to provide additional dental services, with the exception of dental emergencies for a period of up to 90 days after an account becomes delinquent; or where there is pre-payment for additional services. Where appropriate, a credit bureau report may be obtained.



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Dr. Patrick C. Creevan

  • Dr. Patrick C. Creevan - 1964 Fourth St., Livermore, CA 94550 Phone: 925-443-5980