New Patient Form

Pediatric Dentistry of Middle Tennessee - New Patient Form

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

CHILD'S MEDICAL HISTORY

Child's Dental History

Acknowledgment 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.

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:

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.

Clear Signature

New Patient Form

Pediatric Dentistry of Middle Tennessee - New Patient Form

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

CHILD'S MEDICAL HISTORY

Child's Dental History

Acknowledgment 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.

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:

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.

Clear Signature
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