Dentistry for Children & TeensOrthodontics for All Ages

NICKNAME

SSN Driver’s License #

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SSN Driver’s License #*

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Marital Staus: Single Married Divorced If married, Spouse’s name:

Marital Staus: Single Married Divorced If married, Spouse’s name:

Emergency Contact: Name Phone:

1755 Erringer Road, Suite 20 • Simi Valley, CA 93065 • phone: 805.522.2164 • fax: 805.522.9849

Dental History

Have there been any injuriesto your child’s face/mouth/teeth? Yes No

Does

How often does your child brush? Is dental floss used?

Is tooth brushing supervised?By Whom? When?

your child have anyspeech problems? Yes No

Has your child experienced any unfavorable reaction from previous dental or medical care?

Is there anything regarding your child’s physical, mental or emotional health that you feel we should know?

I hereby authorize Dr. Nina Mandelman, Dr. Ahsan Raza and/or their associates to perform any and all treatment for my above named child andconsent to such methods, drugs and agents as may be indicated in connection with his/her dental care. This consent shall remain in effect untilcancelled.

Signature

PLEASE NOTE: Payment is expected for services rendered at the time of the first visit. If the family is not living together, the parentbringing the child to appointments is responsible for the account.

I HAVE REVIEWED MY CHILD’S MEDICAL HISTORY AND IT IS CORRECT. (Please initial and date in the space provided below)

Relationship to Child Date

Is this your child’s first dental visit?Previous DentistDate of Last Visit

How do you think your child will act towards the dentist?

Do you have any specific dental concerns that you want addressed?

Yes No Yes No

Yes No Does your child receive Fluoride?From what source

Yes No

Does your child have any habits such asThumb or finger sucking, pacifier use, nailbiting, lip/cheek biting? Yes No

Yes No

Yes No

Does your child clench or grind their teeth?

Is your child currently nursing or using a bottle?Age discontinued?

Medical History

Is

Child’s Height Weight

your child in good health? Yes No

Does If so, what?

your child have any history of major illness? Yes No

Check any of the following for which your child has been treated: Diabetes Kidney involvement

Pneumonia Tuberculosis

Heart trouble AIDS

ADD/ADHD Prolonged Bleeding

Bone disorder Fainting/dizziness

Herpes Nervous disorders

Anemia Liver involvement

Epilepsy Endocrine problems

Asthma Other:

Have the tonsils/adenoids been removed? Yes NoIf so, at what age?

List any drugs/medications your child is taking or has recently taken and for what reasons:

List any allergy or sensitivity to medications or drugsincluding Penicillan, Aspirin, Latex, Sulpha or Nickel

Has your child reached puberty? Yes No

Autism/Sensory Integration Disorder

Is your child currently under the care of a physician? Yes NoIf so, for what?

INITIAL DATE INITIAL DATE INITIAL DATE INITIAL DATE INITIAL DATE INITIAL DATE

Consent to Receive/Exchange Electronic Communications from

Simi Childrens Dental Group

Date: ___________/______________/________________________

Parent/Guardian Name: _____________________________________________________________________

Relationship to Patient(s): ___________________________________________________________________

Patient Name: _______________________________________________ Date of Birth: _________________

Additional Pt: _______________________________________________ Date of Birth: _________________

Additional Pt: _______________________________________________ Date of Birth: _________________

(Initial below)

I _____ DO AGREE

I______ DO NOT AGREE

That the dental practice may communicate with me electronically at the email address and/or mobile

Phone number listed below. For all intensive purposes; my privacy level should be considered equivalent to that

of a postcard. _______________ (Initials)

I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

I further agree that I am responsible for providing the dental practice any updates to my email address

and/or mobile phone number. _____________ (Initials)

My most preferred method of electronic communication: (Initial below)

________Text Messaging Preferred Number #: ( ) _________ - ______________________________

________ Email Preferred Email Address: ____________________________________________________

I would like to receive: (Please select one or both)

____ Information regarding insurance/billing

____ Other / Miscellaneous

I can withdraw my consent to electronic communications at anytime by calling:

(805) 522-2164 any office staff should be able to assist you with this request.

Patient Signature: ____________________________________________ Date: ________________________ Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party

requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does

not constitute legal advice. It covers only HIPAA , not other federal or state law. Changes in applicable laws or regulations may

require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance,

the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.

FINANCIAL AGREEMENT Thank you for choosing Simi Childrens Dental Group to provide your child's dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask. DENTAL INSURANCE: As a courtesy, we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following:

You must provide us with an insurance card and all the information necessary to verify your child's coverage and file your claim.

Although we may estimate your insurance benefits, we are not responsible for its accuracy.

Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is your responsibility.

Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate.

All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment.

Not all the services we provide are covered benefits. Benefits differ from one insurance company to another.

Fees for non-covered services, along with deductibles and copayments are due at the time of treatment.

Please contact your insurance company with any questions you may have. PATIENTS WITHOUT INSURANCE COVERAGE: A written estimate of fees will be provided for future treatment and payment is expected at each visit for services rendered. A discount may be applied at check out when treatment is rendered, please ask for details. PAYMENT POLICY • We accept cash, debit cards, Visa, MasterCard, Discover and American Express, and Care Credit. • Insurance companies are supposed to process claims within 30 days of receipt. Unfortunately, this does not always happen. After dental insurance has paid its portion, a statement for the remaining balance will be sent to your mailing address on record. In order to avoid finance charges payment is expected within 30 days of the statement date unless other arrangements have been made. FINANCE CHARGES AND COLLECTION FEES: Finance charges will be applied to all balances not paid within 30 days of the monthly billing date. A late charge of 1.5% of the unpaid balance will be assessed each month until paid. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. We understand temporary financial problems may affect timely payment of your balance. In those situations we encourage you to communicate any such problems immediately so we may assist you in the management of your account. ORAL SEDATION: When scheduling an oral sedation, I understand that most insurance does not cover this charge. A sedation fee of $173 is due in full at the time of scheduling and is applied towards treatment. This fee is not discounted for any reason. All other treatment fees, deductibles and co-payments are due on the day service is rendered.

IV SEDATION: When scheduling IV sedation, I understand that insurance may not cover this charge. A sedation fee is due in full, along with all estimated dental deductibles and co-payments on the day service is rendered. This fee is not discounted and is not refundable for any reason. The parent or guardian accompanying the minor is responsible for payment in full, unless prior arrangements for payment have been made. MINOR PATIENTS: The parent or guardian accompanying the minor is responsible for the full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment. This office will not attempt to collect payment from a parent that is not present in the office at that visit. RETURNED CHECKS:A $25.00 charge is applied when a check is returned by the bank. OVERDUE BALANCE: An account with an unpaid balance past 90 days will be sent to a collection agency. Collection fees of approximately 40% are added to the account when it is turned over to an agency. FEE FOR MISSED APPOINTMENT IF 24-HOUR IS NOTICE NOT GIVEN: To reschedule or cancel an appointment, you must notify us at least twenty-four (24) hours in advance to avoid a missed appointment fee of $75.00 per appointment. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept.

CONSENT & AUTHORIZATION: I authorize dental treatment on my child and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understood this document in its entirety, outlining office policies and financial policies of Simi Childrens Dental Group. Without any reservations, I agree to abide by the policies outlined herein. Form completed by: Name (Printed): _____________________________________________________________________________ Signature___________________________________________________ Date: _________________________ Your relationship to child / children: _____________________________________________________________ Child’s Name_________________________________________________ DOB: _________________________ Child’s Name_________________________________________________ DOB: _________________________ Child’s Name_________________________________________________ DOB: _________________________ Child’s Name_________________________________________________ DOB: _________________________

Are you the person legally responsible for this child? Yes ______ No _______