Fill Out Form Child Patient Registration

206-487-7800 • 1515 N. 200TH ST., SHORELINE, WA 98133

New Child Patient Registration Fields marked with * are required

First Name & Middle Initial *

Last Name *

Preferred Name

Gender * Male Female

Date Of Birth *

Home Address *

Apt. or Ste. (optional)

City *

State *

Zip *

Home Phone *

Emergency Phone

I (we) Prefer Communication By Phone Text Email Work All

Student Status

Previous Dentist Name

Previous Dentist Phone

Last Visit Date

Date of last X-Rays

Was it a positive Experience and if not please explain?

What would you like us to do for your child today?

Is your child currently under the care of a physician? * Yes No

Physician(MD) Name

Physician(MD) Phone

Mother's Information Fields marked with * are required

First Name & Middle Initial

Last Name

Preferred Name

Date of Birth

SSN

Home Phone

Cell Phone

Emergency Phone

Employer

Occupation

Father's Information Fields marked with * are required

First Name & Middle Initial

Last Name

Preferred Name

Date of Birth

SSN

Home Phone

Cell Phone

Emergency Phone

Employer

Occupation

Responsible Party (if someone other than mother or father) Fields marked with * are required

Relation To Patient

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

SSN

Address

Address (optional)

City

State

Zip

Home Phone

Cell Phone

Emergency Phone

Employer

Occupation

Primary Insurance Fields marked with * are required

Dental Coverage * Yes No

Orthodontic Coverage * Yes No

Insurance Company Name

SSN or ID Number

Group Number

Phone Number

Subscriber's First Name

Subscriber's Last Name

Subscriber's Date of Birth

Relationship to Patient

Insurance Company's Address

City

State

Zip

Employer

Secondary Insurance Fields marked with * are required

Dental Coverage Yes No

Orthodontic Coverage Yes No

Insurance Company Name

SSN or ID Number

Group Number

Phone Number

Subscriber's First Name

Subscriber's Last Name

Subscriber's Date of Birth

Relationship to Patient

Insurance Company's Address

City

State

Zip

Employer

Emergency Contact (other than parents) Fields marked with * are required

His / Her Name

Relationship

Primary Phone

Work Phone

Health History Fields marked with * are required

Is your child taking any form of fluoride: Tablets, Drops, Rinse, or Gel?

Does your child have speech problems and if so please describe?

Has your child ever been evaluated or had orthodontic treatment before? * Yes No

Have there been any injuries to the face, mouth, teeth, or chin? * Yes No

Has your child ever been hospitalized? * Yes No

If Yes:

Has your child been informed of any missing or extra permanent teeth? * Yes No

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)? * Yes No

Does your child brush his / her teeth daily? * Yes No

Please describe your child's current physical health

Because conditions of the mouth can be hereditary, it is helpful to know if your child is adopted. Yes No

Is your child taking any medications? * Yes No

IF YES, PLEASE LIST THE MEDICATIONS AND PURPOSES:

Does / Did Your Child Have Any Of The Following Habits Fields marked with * are required

Clenching / Grinding * Yes No

Lip Sucking / Biting * Yes No

Mouth Breather * Yes No

Nail Biting * Yes No

Nursing Bottle * Yes No

Speech Problems * Yes No

Thumb / Finger Sucking * Yes No

Tongue Thrust * Yes No

ANY OTHER HABITS WE SHOULD KNOW ABOUT?

Is Your Child Allergic To Any Of The Following Fields marked with * are required

Asprin * Yes No

Penicillin * Yes No

Codeine * Yes No

Are you allergic to Acrylic? * Yes No

Are you allergic to Metal? * Yes No

Are you allergic to Latex? * Yes No

Are you allergic to Sulfa Drugs? * Yes No

Are you allergic to Local Anesthetics? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Please list any other drug/materials that your child is allergic to:

Does / Did Your Child Have Any Of The Following Fields marked with * are required

ADHD

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Headaches

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Has your child ever had any serious illness not listed? * Yes No

If Yes:

Comments

How Did You Hear About Our Office? Fields marked with * are required

Dentist

Internet

Location / Sign

Family / Friend

OFFICE WEBSITE

SOCIAL MEDIA, E.G. FACEBOOK, ETC.

INSURANCE

PLEASE LIST THE NAME

Terms And Conditions Fields marked with * are required

Terms (Required) *

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Release Authorization Fields marked with * are required

I authorize Dr Eric Yao's office to release my medical and/or billing information to the following individuals:

Photo and Testimonial Full Release

I hereby grant permission to Eric S. Yao, DDS, MAGD or any of his staff members to take photographs or videos of my child's teeth, jaws, and face. I understand that my child's photographs, slides, videos, and my patient testimonial can be used for educational lectures, marketing and advertising for this dental practice (including Dr. Eric S. Yao's website, Facebook posts, YouTube, magazines/journal, and other social media). I also understand that if my child's photographs, slides, and videos are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used. I do not expect compensation, financial or otherwise, for the use of these photographs.

I acknowledge Eric S. Yao, DDS, MAGD's right to crop or otherwise treat the photograph at his discretion. I also acknowledge that Dr. Eric S. Yao may choose not to use my child's photograph and testimonial at this time, but may do so at his own discretion at a later date. I also understand that once my child's image is posted on Dr. Eric S. Yao's website, Facebook, YouTube, and other social media, the image can be downloaded by any computer user, which is beyond the control of Dr. Eric S. Yao, and I will hold him and any of his affiliated offices harmless from any such use or download.

I hereby freely and voluntarily consent to the use of my child's photograph and testimonial as stated above until I revoke this consent in writing.

Photo and Testimonial Partial Release

I agree to the above but only agree to have my child's teeth shown without any identifying features. (Please check one or the other, or none)

Health Credit Assessment Consent

I understand that by providing a signature below, I certify that all the information provided is true and correct, and am confirming I have read and understand the Privacy Policy and am providing written instructions to this practice under the FCRA authorizing this practice to obtain information from my personal credit profile from one or more credit reporting agencies. I authorize this practice to obtain such information solely to conduct a prequalification for credit for your health credit assessment.

Form Signature Fields marked with * are required

Print Guardian Name *

Relationship To Patient *

Date: 4/23/2024

Patient Financial Policy Fields marked with * are required

Financial Policies (Required) *

Please click here to review the details of our Financial Policy Agreement Financial Policies Agreement. I acknowledge that I have received and agree to the Financial Policies Agreement.

Payment Options - cash/check, credit cards, care credit, in-house payment plan, and Quality Dental Plan membership program.
As a courtesy, we will file your insurance claims for you. Please understand that any expected payment from your insurance is an estimate only.
A 50% deposit is due at or before the appointment scheduled for all procedures that require laboratory work. (e.g. crowns, implant crowns, bridges, partial dentures, complete dentures, relines, night guards, etc.)
2 BUSINESS DAYS CHANGE OF APPOINTMENT and NO SHOW policy to avoid a $100 administration fee.

Date: 4/23/2024

HIPAA and Privacy Practices Consent Fields marked with * are required

HIPAA Consent (Required) *

I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Date: 4/23/2024

Submit Form Fields marked with * are required

For Official Office Use Only Fields marked with * are required

Dr. Signature

Date

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