New Patient Form Pediatric Dentistry of Middle Tennessee - New Patient FormPlease enable JavaScript in your browser to complete this form.Please contact our office and schedule an appointment BEFORE submitting any documents at our office. If you have already made an appointment, please complete our New Patient form below and click submit. If you would prefer to complete a hardcopy and bring it to our office at your child's appointment, you will find a PDF version at the bottom of this page and you may print the documents and bring them with you. If you have any questions, please call our office at 615-890-0454. We look forward to seeing you and your child/children at your appointment.PATIENT INFORMATIONChild's Name *FirstMiddleLastPreferred NameSex:MaleFemaleDate of Birth: *Social Security Number (SSN):Who may we thank for referring you?Any Family member currently undergoing dental care at Dr. simpson's office?PARENT/GUARDIAN INFORMATIONFather's Name:DOB:SSN:AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer:Email: *Mother's Name:DOB:SSN:AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome #:Cell #:Work #:Employer:Email:Marital Status:MarriedDivorcedWidowedSingleFor confirming appointments, which phone number do you prefer?INSURANCE INFORMATIONInsured Name:ID #Group #Name of Dental Insurance Company:Phone #:Mailing Address of Insurance Company:CHILD'S MEDICAL HISTORYIs your child in good health?YesNoIs your child allergic to any drug or food?YesNoIf Yes, please explain:Does your child have a heart murmur or history of heart murmur?YesNoIf yes, who is your child's cardiologist?Does your child require antibiotics prior to dental treatment?YesNoIf yes, please explain:Is your child under medical care at this time? YesNoIf yes, please explain: Does your child have any conditions which might affect his or her dental treatment?YesNoIf yes, please explain:Is there any history of excessive bleeding in the child or family?YesNoIf yes, please explain: Is there any reason, to your knowledge, why a local anesthetic cannot be used?YesNoIf yes, please explain: Please indicate if your child has had problems with any of the following:Heart SurgeryHeart MurmurRheumatic FeverHIV/AIDSHepatitisDiabetesAsthmaAllergiesAnemiaADHDLiverKidneyCleft Lip/PalateCancer-Chemo therapyFever BlistersHearingEpilepsySinusesEye ProblemsBlood TransfusionUlcersHemophiliaAcid RefluxIrritable Bowel SyndromeCongenital Heart DefectAutism or any ther mental/emotional disorder?YesNoIf yes, please explain: Has any of your immediate family had problems with any of the above?YesNoIf yes, please explain: Has your child ever been hospitalized?YesNoPlease describe any medical history not covered aboveIf yes, Which hospital and for what reason(s)?May we request your child's medical records for our reference?YesNoChild's Dental HistoryDoes your child receive routine check-ups at your family dentist?YesNoIs this your child's first visit to a dentist?YesNoIf no, please enter date of last visitWhat was done for your child at that time? Were X-rays taken?YesNoDoes your child have a history of sucking their fingers?YesNoThumb?YesNoPacifier?YesNoIs either habit still active?YesNoIs your child currently undergoing orthodontic treatment?YesNoOrthodontist:Is your water supply fluoridated? (Consolidated Utility and Murfreesboro City water is flouridated)YesNoDoes your child drink bottled water?YesNoDoes your child receive any flouride supplements?YesNoIf so, what?Does your child brush his/her own teeth?YesNoIf so, how often?Floss?YesNoIf so, how often?Please check any of the folllowing concerns you have with your child's teeth:CavitiesSensitivity to hot & coldCrookedToothacheGum infectionColor of teethSensitivity to sweetsBumped or brokenCrackedAbscessAcknowledgment of Receipt of Notice of Privacy Policies The parent or legal guardian must complete this form for a minor, provide consent for dental treatment, and accompany the child during the initial dental visit. Clinical 1. As the parent/legal guardian of the child(ren) listed above, I authorize Pediatric Dentistry of Middle Tennessee to perform all recommended treatment on the patient, including but not limited to: a. All recommended treatment; b. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis; c. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination. Maintaining Appointments 2. I am aware that when appointments are broken or cancelled at the last minute, valuable clinical time is voided, time that could have been spent serving another patient, especially a patient in pain. I am aware that a failed appointment is an appointment that is cancelled/ rescheduled without 24 hours’ notice or an appointment where a patient does not show up. After two (2) failed appointments, I understand a $75 deposit to hold the appointment time may be required in order for me to reserve any further appointments. After three(3) failed appointments, I risk being dismissed from the practice Financial 3. I am responsible for payment for all services rendered for my child. I understand that payment is due when services are rendered. Insurance 4. I authorize the Practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as “signature on file” and assign to the Practice the insurance benefits providing assignment is accepted. I understand that my dental benefits through my insurance company are not intended to dictate my child’s treatment, only to help offset the cost of dental expenses. I am responsible for payment regardless of coverage provided. HIPAA Acknowledgment 5. I authorize the Practice to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, specialty dentists involved in my child’s care, any and all information, records, and other diagnostic material about my child’s medical history, services rendered, or recommended treatment. 6. I acknowledge receipt of the Notice of Privacy Practices. 7. I authorize sharing my child’s protected health information with the following individuals who may be involved in my child’s care and I understand I am responsible to notify the Practice of any changes. The name(s) listed below are family members or friends to whom I grant permission for Dr. Stephen E. Simpson and representatives at his practice to verbally discuss my child’(s) care using their best judgement and grant them permission to disclose dental information that is relevant to my care such as: appointment changes, cost estimates, account payments/balances, needed treatment/completed treatment. Name:Relationship:Phone:Name:Relationship:Phone:Name:Relationship:Phone:Electronic Communication Consent 8. I agree that Pediatric Dentistry of Middle Tennessee may communicate with me electronically at the email address/mobile number below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am aware that standard text message charges from my cell phone provider may apply. I authorize the following means of communication: Home Number (to include a message):Mobile Number (to include a text message and voice message:E-mailOther:I can withdraw my consent to email/text communications anytime by calling 615-890-0454. Permission: Because your child is a minor, it becomes necessary that signed permission be obtained from the parent or guardian before any and/or all necessary dental services (ex. All procedures and any and all use of drugs that are agreed to be necessary or advisable ) can be performed by Dr. Stephen E. Simpson. Authorization is hereby granted as such. Furthermore, by signing this, I/we agree to be responsible for full payments of the charges for dental services performed on the above named patient regardless of assignment of insurance benefits. Should it be necessary to take action to collect any amount owing under this agreement, I/we agree to assume the costs incurred to collect including but not limited to collection agency fees, attorney fees and court costs. I have read this Patient Consent and agree to all terms and conditions herein. By signing below, you are agreeing to share our mission and abide by our policies concerning your child's dental care needs. Signature Clear Signature DateSubmit New Patient Form Pediatric Dentistry of Middle Tennessee - New Patient FormPlease enable JavaScript in your browser to complete this form.Please contact our office and schedule an appointment BEFORE submitting any documents at our office. If you have already made an appointment, please complete our New Patient form below and click submit. If you would prefer to complete a hardcopy and bring it to our office at your child's appointment, you will find a PDF version at the bottom of this page and you may print the documents and bring them with you. If you have any questions, please call our office at 615-890-0454. We look forward to seeing you and your child/children at your appointment.PATIENT INFORMATIONChild's Name *FirstMiddleLastPreferred NameSex:MaleFemaleDate of Birth: *Social Security Number (SSN):Who may we thank for referring you?Any Family member currently undergoing dental care at Dr. simpson's office?PARENT/GUARDIAN INFORMATIONFather's Name:DOB:SSN:AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer:Email: *Mother's Name:DOB:SSN:AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome #:Cell #:Work #:Employer:Email:Marital Status:MarriedDivorcedWidowedSingleFor confirming appointments, which phone number do you prefer?INSURANCE INFORMATIONInsured Name:ID #Group #Name of Dental Insurance Company:Phone #:Mailing Address of Insurance Company:CHILD'S MEDICAL HISTORYIs your child in good health?YesNoIs your child allergic to any drug or food?YesNoIf Yes, please explain:Does your child have a heart murmur or history of heart murmur?YesNoIf yes, who is your child's cardiologist?Does your child require antibiotics prior to dental treatment?YesNoIf yes, please explain:Is your child under medical care at this time? YesNoIf yes, please explain: Does your child have any conditions which might affect his or her dental treatment?YesNoIf yes, please explain:Is there any history of excessive bleeding in the child or family?YesNoIf yes, please explain: Is there any reason, to your knowledge, why a local anesthetic cannot be used?YesNoIf yes, please explain: Please indicate if your child has had problems with any of the following:Heart SurgeryHeart MurmurRheumatic FeverHIV/AIDSHepatitisDiabetesAsthmaAllergiesAnemiaADHDLiverKidneyCleft Lip/PalateCancer-Chemo therapyFever BlistersHearingEpilepsySinusesEye ProblemsBlood TransfusionUlcersHemophiliaAcid RefluxIrritable Bowel SyndromeCongenital Heart DefectAutism or any ther mental/emotional disorder?YesNoIf yes, please explain: Has any of your immediate family had problems with any of the above?YesNoIf yes, please explain: Has your child ever been hospitalized?YesNoPlease describe any medical history not covered aboveIf yes, Which hospital and for what reason(s)?May we request your child's medical records for our reference?YesNoChild's Dental HistoryDoes your child receive routine check-ups at your family dentist?YesNoIs this your child's first visit to a dentist?YesNoIf no, please enter date of last visitWhat was done for your child at that time? Were X-rays taken?YesNoDoes your child have a history of sucking their fingers?YesNoThumb?YesNoPacifier?YesNoIs either habit still active?YesNoIs your child currently undergoing orthodontic treatment?YesNoOrthodontist:Is your water supply fluoridated? (Consolidated Utility and Murfreesboro City water is flouridated)YesNoDoes your child drink bottled water?YesNoDoes your child receive any flouride supplements?YesNoIf so, what?Does your child brush his/her own teeth?YesNoIf so, how often?Floss?YesNoIf so, how often?Please check any of the folllowing concerns you have with your child's teeth:CavitiesSensitivity to hot & coldCrookedToothacheGum infectionColor of teethSensitivity to sweetsBumped or brokenCrackedAbscessAcknowledgment of Receipt of Notice of Privacy Policies The parent or legal guardian must complete this form for a minor, provide consent for dental treatment, and accompany the child during the initial dental visit. Clinical 1. As the parent/legal guardian of the child(ren) listed above, I authorize Pediatric Dentistry of Middle Tennessee to perform all recommended treatment on the patient, including but not limited to: a. All recommended treatment; b. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis; c. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination. Maintaining Appointments 2. I am aware that when appointments are broken or cancelled at the last minute, valuable clinical time is voided, time that could have been spent serving another patient, especially a patient in pain. I am aware that a failed appointment is an appointment that is cancelled/ rescheduled without 24 hours’ notice or an appointment where a patient does not show up. After two (2) failed appointments, I understand a $75 deposit to hold the appointment time may be required in order for me to reserve any further appointments. After three(3) failed appointments, I risk being dismissed from the practice Financial 3. I am responsible for payment for all services rendered for my child. I understand that payment is due when services are rendered. Insurance 4. I authorize the Practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as “signature on file” and assign to the Practice the insurance benefits providing assignment is accepted. I understand that my dental benefits through my insurance company are not intended to dictate my child’s treatment, only to help offset the cost of dental expenses. I am responsible for payment regardless of coverage provided. HIPAA Acknowledgment 5. I authorize the Practice to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, specialty dentists involved in my child’s care, any and all information, records, and other diagnostic material about my child’s medical history, services rendered, or recommended treatment. 6. I acknowledge receipt of the Notice of Privacy Practices. 7. I authorize sharing my child’s protected health information with the following individuals who may be involved in my child’s care and I understand I am responsible to notify the Practice of any changes. The name(s) listed below are family members or friends to whom I grant permission for Dr. Stephen E. Simpson and representatives at his practice to verbally discuss my child’(s) care using their best judgement and grant them permission to disclose dental information that is relevant to my care such as: appointment changes, cost estimates, account payments/balances, needed treatment/completed treatment. Name:Relationship:Phone:Name:Relationship:Phone:Name:Relationship:Phone:Electronic Communication Consent 8. I agree that Pediatric Dentistry of Middle Tennessee may communicate with me electronically at the email address/mobile number below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am aware that standard text message charges from my cell phone provider may apply. I authorize the following means of communication: Home Number (to include a message):Mobile Number (to include a text message and voice message:E-mailOther:I can withdraw my consent to email/text communications anytime by calling 615-890-0454. Permission: Because your child is a minor, it becomes necessary that signed permission be obtained from the parent or guardian before any and/or all necessary dental services (ex. All procedures and any and all use of drugs that are agreed to be necessary or advisable ) can be performed by Dr. Stephen E. Simpson. Authorization is hereby granted as such. Furthermore, by signing this, I/we agree to be responsible for full payments of the charges for dental services performed on the above named patient regardless of assignment of insurance benefits. Should it be necessary to take action to collect any amount owing under this agreement, I/we agree to assume the costs incurred to collect including but not limited to collection agency fees, attorney fees and court costs. I have read this Patient Consent and agree to all terms and conditions herein. By signing below, you are agreeing to share our mission and abide by our policies concerning your child's dental care needs. Signature Clear Signature DateSubmit Click to open a PDF version of this form Click HERE to DOWNLOAD a PDF version of our New Patient form to your computer