Child’s Name ________________________________________

Last First MI Goes by: ______________________ Male Female

Siblings that we treat __________________________________

Child’s Birthdate _____/_____/_____ Child’s Age ___________

School_____________________________Grade____________

Child’s Home # (__________)___________________________

SS#________________________________________________

Child’s Home Address:_________________________________

___________________________________________________

City State Zip Email Address:_______________________________________

Name _______________________________________________

Relationship__________________________________________ Do you have legal custody of this child? Yes No

Insurance Co. Name ___________________________________

Insurance Co. Address _________________________________

____________________________________________________

Insurance Co. Phone # (___________)_____________________

Group # (Plan, Local, or Policy #) _________________________

Policy Owner’s Name __________________________________

Relationship to Patient__________________________________

Policy Owner’s Birthdate ______/ ______/ ______

Social Security # ______________________________________

Policy Owner’s Employer _______________________________

Name_______________________________________________

Relationship__________________________________________

Billing Address _______________________________________

____________________________________________________

City State Zip

Home # (____________)________________________________

Work # (____________)________________________________

Cellular # (___________)________________________________

E-mail ______________________________________________

Name ______________________________________________

Mother Stepmother Guardian Birthdate _____/_____/_____

Employer ___________________________________________

Work # (_________)____________________ Ext. __________

Home # (_________)__________________________________

Cellular Phone # (_________)___________________________

SS # _____________________ DL# _____________________

NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service.

Tell Us About Your Child

Mother’s Information

Primary Dental Insurance

Person Responsible for Account

Who is Accompanying the Child Today?

Father’s Information

Name ______________________________________________

Father Stepfather Guardian Birthdate _____/_____/_____

Employer ___________________________________________

Work # (_________)____________________ Ext. __________

Home # (_________)__________________________________

Cellular Phone # (_________)___________________________

SS # _____________________ DL# _____________________

Secondary Dental Insurance

Insurance Co. Name ___________________________________

Insurance Co. Address _________________________________

____________________________________________________

Insurance Co. Phone # (___________)_____________________

Group # (Plan, Local, or Policy #) _________________________

Policy Owner’s Name __________________________________

Relationship to Patient__________________________________

Policy Owner’s Birthdate ______/ ______/ ______

Social Security # ______________________________________

Policy Owner’s Employer _______________________________

Who may we thank for referring you to our office?

___________________________________________________

Health History Form Today’s Date: _______________

Page 1 of 2

1. 5.

6.

2.

7. 3.

8. 4.

2005 St. Charles Street

Suite 1

Jasper, Indiana 47546

Phone: 812 634-7409

Seng Pediatric Dentistry, P.C. Nathan C. Seng, D.D.S.

2005 St. Charles Street, Suite 1 Jasper, IN 47546

CONSENT TO TREATMENT: Your signature on this document grants your consent and gives permission to Seng Pediatric Dentistry for dental and oral health care treatment.

ACKNOWLEDGMENT OF HIPPA NOTICE OF PRIVACY PRACTICES: I hereby acknowledge that I have read a copy of Seng Pediatric Dentistry’s HIPPA NOTICE OF PRIVACY PRACTICES. A copy of this document is available to me upon request.

MEDICAID SUBSCRIBERS: For these individuals, Seng Pediatric Dentistry accepts and files claims for Medicaid/Hoosier Healthwise. For any service that is not covered by Medicaid/Hoosier Healthwise the patient understands they are fully responsible for that amount.

INSURANCE AUTHORIZATION, ASSIGNMENT OF BENEFITS, AND RELEASE: I hereby agree to Seng Pediatric Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges and fees incurred at Seng Pediatric Dentistry whether or not these charges and fees are covered or paid for by my dental insurance plan. I hereby authorize Seng Pediatric Dentistry to release all information necessary to secure the payment of such benefits. I authorize the use of this signature on all my insurance submissions, be they manual or electronic.

FINANCIAL GUIDELINE AND PAYMENT AGREEMENT: It is the goal of Seng Pediatric Dentistry to provide you with the best dental health care possible. With that in mind, there may be certain routine services that we feel are necessary for the maintenance of good oral health that may not be covered by your insurance plan. Your signature below indicates your understanding that you assume full financial responsibility to pay for any and all services performed at Seng Pediatric Dentistry not covered by your insurance plan. Your signature below indicates understanding and agreement of the following:

1. We accept payment by cash, check, Visa, MasterCard, Discover, or payment plan via CARE CREDIT 2. ALL co-payments are due at time of service. 3. Checks returned by your bank for nonpayment are subject to a $30.00 returned check fee.

Without exception, full payment for any and all dental procedures performed at Seng Pediatric Dentistry is due and payable at the time of service. Finance charges and billing fees will be assessed against your account if we find it necessary to process an overdue account statement. Furthermore, I understand and agree that should my account become more than 90 days overdue, the collections process will proceed in one of the following ways.

• Suit will be filed with the Clerk of the Circuit Court of Dubois County, Small Claims Division, for full payment, including finance charges, billing fees, and any and all costs incurred should such action need be taken.

FAILED APPOINTMENT/CANCELLATION GUIDELINE: It is important and expected that you arrive on time for your scheduled appointments. Your appointment time is scheduled specifically for you, and this time is mutually agreed upon at the time when said appointment is scheduled. A reminder telephone call or text message will be done two days prior to your appointment and we ask that you confirm the scheduled appointment time. Your account will be charged a $25.00 cancellation fee for any appointments that are failed or cancelled without the courtesy of a 48 hour notice. In the event that 2 appointments have been missed without a 24 hour notice, we will no longer be able to treat you and/or your family at our practice. If you are 15 minutes late for your scheduled appointment, due to the courtesy of seeing other patients on time, this will be counted as a missed appointment and will need to be rescheduled.

Authorization for Non-Parent/Guardian to Accompany Patient

Periodically there may be times when a parent/guardian are unable to bring their child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization allowing this person to accompany your child(ren). The person bringing your child will need to present a photo ID at the time of service.

This authorization gives the persons listed below permission to bring your child(ren) to their appointments, speak to the doctor and the entire SPD team, and give consent for dental treatment.

________________________________________ ________________________________ Name of Person (allowed to bring child) Relationship

________________________________________ ________________________________ Name of Person (allowed to bring child) Relationship

__________________________________________________________________________________________________

ACKNOWLEDGMENT: I certify that I have read and understand the guidelines set forth above and therefore agree to pay for any and all services rendered not covered by my insurance plan. I also understand that specific services may not be covered by my insurance and any estimates of insurance coverage discussed by any staff member were provided to me as a courtesy. It is my responsibility to contact my child’s dental insurance company to discuss and understand my child’s policy. I also agree to be responsible for and agree to pay for any and all cancellation fees as well as any court costs incurred for the collection of any debt I incur with Seng Pediatric Dentistry.

Patient’s Name: ______________________________________________

Printed Name of Parent/Guardian: _______________________________

Signature of Parent/Guardian: _________________________________________________ DATE:_________________