Elizabeth Mueller, D.D.S. & Associates Specialists in Children’s … · 2019-01-30 · Very...
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Elizabeth Mueller, D.D.S. & Associates Specialists in Children’s Dentistry Patient’s Name______________________________________NickName_________________________ Age_________ Sex_____ Race__________________D.O.B._____________Place of Birth____________________________________ Patient’s Address__________________________________________________Patient’s Cell Phone_________________ Street City State Zip Parent #1___________________________________DOB________________Social Security______________________ Marital Status: Single Married Separated Divorced Widowed Address______________________________________________________________Home Phone__________________ Street City State Zip Email Address _________________________________________________________Cell Phone___________________ Where Employed_______________________________________________________Work Phone__________________ Employer’s Address________________________________________________________________________________ Street City State Zip Dental Insurance___________________________________________________________________________________ Company Policy Number Group Number Member ID Number _________________________________________________________________________________________________ Street City State Zip Phone Parent #2___________________________________DOB________________Social Security______________________ Marital Status: Single Married Separated Divorced Widowed Address_______________________________________________________________Home Phone_________________ Street City State Zip Email Address __________________________________________________________Cell Phone__________________ Where Employed________________________________________________________Work Phone_________________ Address__________________________________________________________________________________________ Street City State Zip Dental Insurance___________________________________________________________________________________ Company Policy Number Group Number Member ID Number _________________________________________________________________________________________________ Street City State Zip Phone Stepfather’s Full Name _______________________________________ Home Phone ________________ Work Phone ___________________ Stepmother’s Full Name ______________________________________ Home Phone ________________ Work Phone ___________________ Child’s Physician___________________________________Parent’s Dentist___________________________________ Whom may we thank for referring you to our office?_______________________________________________________ Health History Date of your child’s last physical_________________ Is your child up to date with immunizations? Yes No Is your child currently undergoing any medical treatment? If so what?__________________________________ Is your child in speech, occupational or physical therapy? If so what? _________________________________ Is your child currently taking any medications? If so what? _________________________________ Has your child ever had an allergic reaction to food, medication, or other? _________________________ Does your child experience canker sores and/or fever blisters? Yes No Has your child been hospitalized since birth? ____________________________________________ Date Reason Has your child had surgery or general anesthesia? ____________________________________________ Date Reason Complications Check all that appl * Heart Conditions * Respiratory Problems * Epilepsy/Seizure Disorder * Craniofacial Problems * Bleeding Problems * Hepatitis/Liver/Kidney * AIDS * STD * Pregnant * Seasonal Allergies/Sinus * Anxiety * Family history of Anxiety * Sensory Integration * Autism/Aspergers * Intellectual Disabilities * Vision Problems * Hearing/Ear Problems * Speech Problems * Cerebral Palsy * Mental Health Issues * ADD/ADHD * Learning Problems * Diabetes * Other________________ If yes to any of above, please detail here_________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Transcript of Elizabeth Mueller, D.D.S. & Associates Specialists in Children’s … · 2019-01-30 · Very...
Elizabeth Mueller, D.D.S. & Associates Specialists in Children’s Dentistry Patient’s Name______________________________________NickName_________________________ Age_________ Sex_____ Race__________________D.O.B._____________Place of Birth____________________________________ Patient’s Address__________________________________________________Patient’s Cell Phone_________________ Street City State Zip Parent #1___________________________________DOB________________Social Security______________________ Marital Status: Single Married Separated Divorced Widowed Address______________________________________________________________Home Phone__________________ Street City State Zip Email Address _________________________________________________________Cell Phone___________________ Where Employed_______________________________________________________Work Phone__________________ Employer’s Address________________________________________________________________________________ Street City State Zip Dental Insurance___________________________________________________________________________________ Company Policy Number Group Number Member ID Number _________________________________________________________________________________________________ Street City State Zip Phone Parent #2___________________________________DOB________________Social Security______________________ Marital Status: Single Married Separated Divorced Widowed Address_______________________________________________________________Home Phone_________________ Street City State Zip Email Address __________________________________________________________Cell Phone__________________ Where Employed________________________________________________________Work Phone_________________ Address__________________________________________________________________________________________ Street City State Zip Dental Insurance___________________________________________________________________________________ Company Policy Number Group Number Member ID Number _________________________________________________________________________________________________ Street City State Zip Phone Stepfather’s Full Name _______________________________________ Home Phone ________________ Work Phone ___________________
Stepmother’s Full Name ______________________________________ Home Phone ________________ Work Phone ___________________
Child’s Physician___________________________________Parent’s Dentist___________________________________
Whom may we thank for referring you to our office?_______________________________________________________
Health History
Date of your child’s last physical_________________ Is your child up to date with immunizations? Yes No Is your child currently undergoing any medical treatment? If so what?__________________________________ Is your child in speech, occupational or physical therapy? If so what? _________________________________ Is your child currently taking any medications? If so what? _________________________________ Has your child ever had an allergic reaction to food, medication, or other? _________________________ Does your child experience canker sores and/or fever blisters? Yes No Has your child been hospitalized since birth? ____________________________________________ Date Reason Has your child had surgery or general anesthesia? ____________________________________________ Date Reason Complications
Check all that apply
* Heart Conditions * Respiratory Problems * Epilepsy/Seizure Disorder * Craniofacial Problems * Bleeding Problems * Hepatitis/Liver/Kidney * AIDS * STD * Pregnant * Seasonal Allergies/Sinus * Anxiety * Family history of Anxiety
* Sensory Integration * Autism/Aspergers * Intellectual Disabilities * Vision Problems * Hearing/Ear Problems * Speech Problems * Cerebral Palsy * Mental Health Issues * ADD/ADHD * Learning Problems * Diabetes * Other________________
If yes to any of above, please detail here_________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Dental History Purpose of today’s visit or chief concern?______________________________________________________________ Is this your child’s first dental visit? Yes No Date of last visit____________________________ Any previous X-Rays Yes No Location____________________________________________________________________________________ Who brushes your child’s teeth? ___________________________________ How Often? _______________________ Any oral habits (thumb sucking, pacifier, nail biting, etc.)? Yes No Was your child breast fed? Yes No How long? ________ Was your child bottle-fed? Yes No How long? ________ Is your child going to sleep with a bottle? Yes No What does the bottle contain: Water Milk Formula Juice Other _________________________ Has your child had an unfavorable experience in the dental office? Yes No Explain_____________________________________________________________________________________ Have YOU had an unfavorable experience in the dental office? Yes No Explain_____________________________________________________________________________________ Is your water fluoridated? Yes No Do you have a water filtration system? Yes No What type? __________________________________________________________________________________ Social History Is this your biological child? Yes No With whom does the child live? ______________________________________________________________________ Are there brothers and sisters in the home? Yes No Names and Ages? ____________________________________________________________________________ Does your child have an in-home babysitter or go to a babysitter? Yes No Name? ____________________________________________________________________________________ Hobbies? _________________________________________________________________________________________ What school, preschool, or daycare does your child attend?________________________________________________ Has your child ever repeated a grade? Yes No What Grade? ______ Has your child been in special classes, received an IEP from the state of Ohio, Kentucky, Indiana or a CCDD evaluation?
Behavior Evaluation Parental Questionnaire
My child enjoys swimming. Yes No My child enjoys getting a haircut. Yes No My child plays well with other children. Yes No When exposed to a new situation, my child tends to be shy and timid. Yes No I expect that my child will be cooperative for dental treatment. Yes No When I must give liquid medication, my child will swallow it Only if forced Only if coaxed Willingly I agree to diagnostic procedures and dental treatment as found necessary and explained by Elizabeth Mueller, D.D.S. & Associates for the patient names above. As a parent or guardian of a new patient, I am responsible for my account the day of service. If insurance should not pay within 30 days, I will be billed immediately. Any accounts not paid in full within 60 days will receive a service charge of 1.5% a month. Appointments cancelled without 48 hours notice will incur a fee.
______________________________________________________________________________________________ Date Signature of person legally responsible
AppointmentCommitment
Youhavemadeanappointmentforyourchild’sdentalcare.Inourpractice,therearetwotypesofappointments:
1. Operative/Treatment-ScheduledwithDr.Mueller,Dr.Doss,orDr.Thomas2. Preventive/Cleaning-Scheduledwiththeadentalhygienist
Allourappointmentsareinlimitedsupply.Onceyouhavemadeanappointment,time,trainedpersonnelanddentalequipmentarereservedspecificallyforyourchild’sprocedure.Werespectyourtimeandaskthatyourespectoursbyhonoringyourappointmentcommitment.Abrokenappointmentisalosstoeveryone,includingotherchildrenawaitingtreatment.Forthisreason,itisimportantthatyounotifyourofficeatleast48hours(72hoursforfamilyappointments)priortothescheduledtimeifyouhavetoreschedule.Thiscourtesyenablesustoaccommodatetheneedsofyourandotherschildrenmorereadily.Wereservetherighttochargeforthetimereservedifyoufailtokeeptheappointmentorcancelwithlessthan48hoursnotice-$50foroperativeand$25forpreventiveappointments.FinancialAgreementIfweareworkingwithyourdentalinsurance,pleaserememberthatyourdeductibleandyourinitialresponsibility(40%)aredueatthetimeofyourchild’streatment.Becausewebelievethatdentalhealthshouldbeaccessibletoallpatients,ourFinancialCoordinatorisavailabletodiscussthefinanceoptionsthatourofficeoffers.________________________________________________
ElizabethMueller,DDS&Associates
9200MontgomeryRoad,Suite4B6396ThornberryCourt,Suite720Cincinnati,Ohio45242Mason,Ohio45040
EASYPAYPLAN
Dr.ElizabethMuellerandAssociatesiscommittedtoreducingwasteandinefficiency,whilemakingourbillingprocessassimpleandeasyaspossible.WearenowabletokeepyourHSAcardandcreditcardnumberonfileinourHIPAA-compliant,securepracticemanagementsoftware.Thissystemstoresthecardinformationforfuturetransactions,usingthesametechnologyanonlineretailerwould.Wecan'tseethecardnumber,onlythelast4numbers,givingusnowaytousethecardoutsideofourbillingsystem.CreditCardsonfilewillbeusedtopayaccountbalancesafterinsurancehaspaidtheirportion.Onceyourinsurancehasprocessedyourclaims,theywillsendyouanExplanationofBenefits(EOB)showingwhatyouareresponsibleforpaying.YoutypicallyreceivetheEOBbeforeus,soifyoudisagreewiththepatientresponsibilityamountowed,itisyourresponsibilitytocontactyourinsurancecarrierandourbillingdepartment.Ifyoufailtoprovideourofficewithcurrentinsuranceinformation,yourclaimwillbedeniedandyourcreditcardonfilewillbecharged. EasyPaypaymentswillbeprocessedonceyourinsurancehasbeenpaid.Areceiptwillbee-mailedtoyouforyourrecords.TheEasyPayPlanwillhelpustocutdownonadministrativecosts.Ourstaffspendslesstimeontakingcreditcardinformationoverthephoneorenteringitfrombillingslipssentinthemail(it'smuchmoresecurethanthoseoptions!).Usingthissystemallowsustosendoutfewerstatements,savingtrees,moneyandtime.Wecanspendourtimeonthingswethinkaremoreimportant,likefollowingupwithinsuranceclaims,helpingpatientsonthephone,inperson,andworkingtomakeyourvisitthebestitcanbe.Firstandforemost,itisfarmoreconvenientforyou!Youdon'thavetocalltheofficeorbuyastamp!Ifthissoundsrightforyou,pleaseinformourBusinessManager,SandraCarroll.Thankyou,Dr.ElizabethMuellerandAssociates
ElizabethMueller,DDS&Associates
9200MontgomeryRd.6396ThornberryCourtCincinnati,Ohio45242Mason,Ohio45040
CREDITCARDONFILEPOLICY
AtDr.ElizabethMueller&Associates,keepingyourcreditordebitcardonfileasaconvenientmethodofpaymentfortheportionofservicesthatyourinsurancedoesn’tcover,butforwhichyouareliable.Withoutthisauthorization,abillingfeeof2.00willbeaddedtoyouraccountforanybalancesover60daysthatwemustattempttocollectthroughmailingmonthlystatement.Yourcreditcardinformationiskeptconfidentialandsecure.Paymentstoyourcardareprocessedonlyaftertheclaimhasbeenfiledandprocessedbyyourinsurer,andtheinsuranceportionoftheclaimhasbeenpaidandpostedtotheaccount.IauthorizeDr.ElizabethMueller&Associatestochargetheportionofmybillthatismyfinancialresponsibilitytothefollowingcreditordebitcard:☐ Amex☐ Visa☐ Mastercard☐ DiscoverCreditCardAccountNumber___________________________________ExpirationDate_____/_____/_____SecurityCode___________________CardholderName_____________________________________________Signature____________________________________________________BillingAddress_______________________________________________City_____________________State_______Zip____________________I(we),theundersigned,authorizeandrequestDr.ElizabethMueller&Associatestochargemycreditcard,indicatedabove,forbalancesdueforservicesrenderedthatmyinsurancecompanyidentifiesasmyfinancialresponsibility.ThisauthorizationrelatestoallpaymentsnotcoveredbymyinsurancecompanyforservicesprovidedtomebyDr.ElizabethMueller&Associates.ThisauthorizationwillremainineffectuntilI(we)cancelthisauthorization.Tocancel,I(we)mustgivea60daynotificationtoDr.ElizabethMueller&Associatesinwritingandtheaccountmustbeingoodstanding.ResponsiblePartyName(Print):____________________________________________Signature:______________________________________________________________Date:_____/_____/_____
ElizabethMueller,DDS&Associates
INFORMEDCONSENTFORPEDIATRICDENTALTREATMENT
Oneofourmostimportantparentalpoliciesisto"informbeforeweperform."Beforewebegintreatingyourchild,weaskyourpermissionforperiodicdentalexaminations,x-rays,dentalcleaningsandfluorideapplications.Wealsoneedyourpermissiontoperformdentaltreatments,restorationsand/orappliancesasneededtoreturnallteethtohealthandproperfunction,usinglocalanestheticandacomfortablemouthprop.Thepurposeofalltheseproceduresistogainandmaintaindentalhealth,andweexpectgoodresults,althoughnoguaranteesastotheresultsmaybegiven.
Althoughourgoalisthebestoralhealthforyourchild,therearesomeslightrisksinvolvedingettingtothatgoal.Veryrarely,dentaltreatmentmaybeassociatedwithnumbness,bleeding,discoloration,soreness,upsetstomach,dizziness,allergicreaction,swellingandinfection.But,ignoringaknowndentalproblemhasanevengreaterrisk.Nottreatingexistingdentalproblemsinchildrenmayresultinabscess,infection,pain,fever,swelling,considerablerisktothedevelopingadultteeth,andmaycreatefutureorthodonticandgumproblems.
Avisittothedentalofficepresentstheyoungchildwithlotsofnewandunfamiliarexperiences.Itiscompletelynormalforsomechildrentoreacttothesenewexperiencesbycrying.Sometimestheywillusestallingbehaviorssuchasaskingrepetitivequestions,askingfornon-presentparentorstatingtheyneedtogotothebathroom.Alleffortswillbemadetogaintheconfidenceandcooperationofouryoungpatientsbywarmth,humor,gentleunderstandingandfriendlypersuasion.Highqualitydentalcareforchildrenisourgoal.Qualitycarecanbemadeverydifficultorevenimpossible,bythelackofcooperation.
Behaviorsthatcaninterferewithproperdentaltreatmentarehyperactivity,resistivemovements,refusingtoopenthemouthorkeepitopen,andevenaggressiveorphysicalresistancetotreatment.Aggressiveorphysicalresistancetotreatmentcanbescreaming,hitting,kickingandgrabbingthedentist'shandsorgrabbingoursharpdentalinstruments.Ourgoalistoalwaysavoidphysicalharmtothepatient,theparentandourstaffmembers.
Thereareseveralbehaviormanagementtechniquesthatareusedinourofficetohelpchildrengetthequalitydentalcaretheyneed.Theyareasfollows:
A.TELL-SHOW-DOistheuseofsimpleexplanationsanddemonstrationsgearedtothechild'slevelofmaturity.
B.POSITIVEREINFORCEMENTisrewardingthehelpfulchildwithcompliments,praise,apatonthebackandgoldcoinstospendintheTreasureTower.
C.VOICECONTROLisgettingtheattentionofanoisychildbyusingfirmcommandsandvaryingtonesofvoice.
D.NITROUSOXIDE(LAUGHINGGAS)Theuseoflaughinggasisanothersafewaytoprovidedentaltreatmenttomildlyfrightened,buthelpfulchildren.Laughinggascalmschildrenbutdoesnotputthemtosleepornumbtheir
teeth.Ithasfewsideeffectsandlastonlyaslongasthegasisbeingbreathedthroughanosemask.Onextremelyrareoccasions,thegascancauseanupsetstomachandvomiting
E.PHYSICALRESTRAINTBYTHEDENTALTEAMWithanactiveorcombativechild,itissometimesnecessaryforthedentalassistanttorestrainthechild'smovementbyholdingthehead,arms,handsorlegs.Thedentistmayrestrainthechild'sheadbystabilizingitbetweenarmandbody.Atoothpillowmaybeplacedinthechild'smouthtopreventclosingwhenthechildrefusestoopenorhastroublekeepingthemouthopen.
F.PHYSICALRESTRAINTBYPARENTWecallthisrestraintthe"Lap-to-Lap"asthe"pre-cooperative"childsitsontheparent'slap,facingandstraddlingtheparent.Theparentanddentalteammembersitface-to-faceandkneetokneeformingabridge.Thechildlayshisheadinthedentalteammember'slapwhiletheparentholdsthepatient'shandsonthepatient'sbelly.Thiswaythechilddoesnothavetoseparatefromtheirparent.
G.PHYSICALRESTRAINTBYPEDI-WRAP(BLUEBLANKET)Theuseofthistypeofrestraintisastandardofcareinmedicine.ThePedi-WraporBlueBlanket,isthesafestandmostcompassionatewaytoensurequalitydentaltreatmentofanactivechild.Itholdsarms,bodyandlegssecurewithVelcroandclothwrapsduringtreatment.Manytimesafearfulpatientwillcalmdownoncetheyarewrappedintheblanketastheyfeel"snugasabuginarug".THOSEPATIENTSWITHOUTSPECIALNEEDSWILLOUTGROWTHENEEDFORRESTRAINTS!
Beyondthesetechniques,a"pre-cooperative"childmayneeddentaltreatmentwithIVSedationortreatmentinahospital,whichiscoveredinaseparateconsentform.
Ihavereadandunderstandthisinformationonbehaviormanagement.Iunderstandthatdentaltreatmentforchildrenincludeseffortstoguidetheirbehaviorbyhelpingthemunderstandthetreatmentintermsappropriatetotheirage.Ifanytreatmentotherthantheaboveisneeded,itwillbediscussedwithmebeforebeginningsuchtreatment.IunderstandthatImayrefuseanyoralloftheabovetreatmentsorprocedures.Pleasespeaktothedoctoraboutanyofyourconcerns.
Thisconsentwillremaininfullforceunlesswithdrawninwritingbythepersonwhohassignedonbehalfofthisminorpatient.
_____________________________ _______________________________
PRINTCHILD'SNAME PARENT'SORGUARDIAN'SSIGNATURE
_____________________________ ________________________________
WITNESS TODAY'SDATE
THANKYOUFORTAKINGTHETIMETOREADANDSIGNTHISIMPORTANTFORM
