New Patient Information

New Patient Registration Form

FOR NEW PATIENTS ONLY

In order to ensure your/your child's safety, comfort and happiness at the first visit, we need to obtain information from you. Please carefully and completely answer the questions below. Thanks!

* Required Field

* Gender:

Patient Dental History

* Is this the patient's first visit to a dentist?
* Has the patient ever had an unpleasant dental experience?

Family Dental History

Do any dental problems run in your family?

Cavity Prevention History

Does the patient receive flouride daily either through water or a supplement?
Does the patient use a toothpaste containing flouride?
How often are the patient's teeth brushed daily?
Who brushes the patient's teeth?
Is the patient familiar with dental floss?

Growth and Development

Does patient have a bite problem?
Does patient have a speech problem?
Does the patient have any oral habits such as thumb or pacifier, lip or nail biting, grinding, etc.?

Patient Medical History

Has the patient had any history of:

* Heart Condition - Currently being monitored by a cardiologist
{C}
* ADHD
{C}
* Diabetes
* Kidney Disease
{C}
* Liver Disease
{C}
* Epilepsy/Seizures
* Cerebral Palsy
{C}
* Asthma
{C}
* Blood Disorder
* Blood Transfusion
{C}
* AIDS or HIV
{C}
* Hepatitis
* Cancer
{C}
* Radiation Treatment
{C}
* Sickle Cell Anemia
* Anemia
{C}
* Arthritis
{C}
* Delayed Development
* Complications with Nitrous Oxide
{C}
* Complications with Local Anesthesia

For the health and safety of all our patients, Smiles by COO has an automatic rescheduling policy if your child has had a contagious condition within the past 48 hours.

Does patient currently have...

* Fever
{C}
* Flu
{C}
* Strep Throat
* Pink Eye
{C}
* Fever Blisters
{C}
* Ring Worm
* Hand-Foot-and-Mouth
* Any other condition that may prevent the patient from being seen today?
* Is patient allergic to any medications, food, or latex?
* Is patient currently taking any medications?

Responsible Party Information

Responsible Party #1

* Relationship to Patient:
Marital Status:
Primary Phone Number is...:

Responsible Party #2

Relationship to Patient:
Marital Status:
Primary Phone Number is...:
* Does the patient reside with both parents?

Permission is hereby granted to the doctor and staff to perform an initial dental examination and treatment which may include preventive education, x-rays, dental cleaning, fluoride treatment, and orthodontic consultation. (Note: Some insurance plans may not cover some procedures due to age/frequency limitations. Our office will give you an estimate of charges for treatment appointments. Actual charges may differ due to conditions found during treatment. Please remember we accept insurance assignment as a courtesy to you. If your insurance company pays less than the estimated amount or does not pay within 60 days you will be billed for the balance.) I understand and give consent for treatment.

Note: An authorized adult presenting the minor patient for treatment will be responsible for the patient portion due at the time of service unless prior financial arrangements have been set up.

Note: Any patient under 18 must have a consent form on file to attend any appointment without a parent/guardian present for the duration of the appointment. (Ex. If the patient is driving themselves)

Insurance Information

* Is your/your child's dental care covered by a dental insurance program?

If so, please complete the following...

Are you/your child covered by more than one dental program?

Primary Insurance

Secondary Insurance

Finally, please let us know a little more about how you chose our office.

Please note, all forms are available on our website and in our office.

ACKNOWLEGMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES and ACKNOWLEDMENT OF RECEIPT OF NOTICE OF ELECTRONIC DISCLOSURE OF PROTECTED HEALTH INFORMATION

I have received/read the above forms.

Additional Forms/Authorizations

We would love to feature your before and after smile on our website.

I give permission for Dr. Oliver's office to display my or my child's photograph on their office website or other social media sites.

I have had access to the CDO General Office Policies form which includes financial policies and authorization of direct payment of dental insurance benefits to the office of Dr. Jarod and Dr. Celeste Oliver. I have also had access to the Consent for Internet Communications form and give my consent regarding communications.



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