MEDICAL HISTORY FORM

1. Patient Information

2. Health Information

Has your child ever had any of the following? Please check those that apply:
Dental History
1. Has your child been admitted to a hospital or needed emergency care during the past two years?
2. Has your child ever had surgery?
3. Is your child now under the care of a physician for anything other than routine care?
4. Does your child have any health problems that need further clarification?
5. Is your child taking any medications?
7. Has your child ever had any complications following dental treatment?
9. Did your child breast feed?
10. Did your child bottle feed?
11. Were there any problems or complications during pregnancy or delivery?
12. Is your child up to date on his/her immunizations?

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If my child ever has any  change in his/her°health, I will inform the doctors at the next appointment without fail.

Parent/Guardian Signature

3. Responsible Party Info

4. Employment Info

5. Employment Info

Payment is expected at the time of service and can be made by personal check, Visa, MasterCard, American Express, or Discover.

 

As a condition of your treatment by this office, financial arrangements must be made in advance.  The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

 

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for the payment of all dental services.  This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

 

A service charge of 11/2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied. There will be a $25.00 charge for returned checks.

 

I understand that the fee estimate listed for this dental care can only be extended for a period of 60 days from the date of the patient examination.

 

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended.  I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof.

 

 I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if a suit were instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.  

 

In the case of divorce, payment is expected from the parent/guardian who is with -the patient. Parents/guardians are expected to work out payment arrangements with each other and not involve North Shore Dentistry for Children in any disputes.  

 

 We reserve the right to charge $25.00 per half hour of the scheduled time for appointments missed or not canceled within 24 hours prior to the appointment. Charges will not exceed the amount of treatment scheduled.

 

I have read the above conditions of treatment and agree to their content.  I accept full responsibility for the payment of dental services rendered to my child/children by North Shore Dentistry for Children.

Parent/Guardian Signature

6. Exit Survey

Whom may we thank for referring you to our practice?

PHONE
(847) 869-5417
(847) 869-5509 FAX

LOCATION

One Rotary Center
1560 Sherman Avenue, Ste. 610
Evanston, Illinois 60201

HOURS

Mondays, Wednesdays & Thursdays:
7:30 AM — 5:00 PM
Tuesdays: 8:30 AM — 5:00 PM
Fridays: 7:30 AM — 2:00 PM

Saturdays : 8:30 AM — 3:00 PM

Copyright © 2020: All Rights Reserved: North Shore Dentistry for Children