Child Health/ Dental History Form

Child Health/ Dental History Form

Child Health/ Dental History Form

Patients Name
Last First / Nickname / Date of Birth
Parent/ Guardian’s Name / Relationship
Street address City State zip / Sex
__ Male __Female
Home Cell
Please check all that apply:
◊Anemia / ◊Cancer / ◊Epilepsy / ◊HIV/ AIDS / ◊Mononucleosis / ◊Thyroid
◊Arthritis / ◊Cerebral Palsy / ◊Fainting / ◊Immunizations / ◊Mumps / ◊Tobacco/Drug Use
◊Asthma / ◊Chicken Pox / ◊Growth Problems / ◊Kidney / ◊Pregnancy (teens) / ◊Tuberculosis
◊Bladder / ◊Chronic Sinusitis / ◊Hearing / ◊Latex Allergy / ◊Rheumatic Fever / ◊Venereal Disease
◊Bleeding Disorder / ◊Diabetes / ◊Heart / ◊Liver / ◊Seizures / ◊ Other
◊Bones/Joints / ◊Ear Aches / ◊Hepatitis / ◊Measles / ◊Sickle cell / ◊Other

Name of child’s Physician______Phone ______

Childs History

  1. Is the child taking any prescription and or over the counter medications or vitamin supplements at this time?_____ Yes ○No ○

If yes please list. ______

  1. Is the child allergic to any medication, i.e. Penicillin, antibiotics, or other drugs? If yes, explain______Yes ○No ○
  2. Is the child allergic to anything else, such as certain foods? If yes, explain______Yes ○No ○
  3. How would you describe the child’s eating habits? ______
  4. Has the child ever had a serious illness? If yes, explain ______Yes ○No ○
  5. Has the child ever been hospitalized? ______Yes ○No ○
  6. Does the child have a history of any other illness? If yes, explain______Yes ○No ○
  7. Has the child ever received a general anesthetic?______Yes ○No ○
  8. Does the child have any inherited problems? ______Yes ○No ○
  9. Does the child have any speech difficulties? ______Yes ○No ○
  10. Has the child ever had a blood transfusion? ______Yes ○No ○
  11. Is the child physically, mentally, or emotionally impaired? ______Yes ○No ○
  12. Does the child experience excessive bleeding when cut? ______Yes ○No ○
  13. Is the child currently being treated for any illnesses? ______Yes ○No ○
  14. Is this the child’s first visit to the dentist? ______Yes ○No ○
  15. Has the child had any problems with dental treatment in the past? ______Yes ○No ○
  16. Has the child ever had any dental x-rays taken? ______Yes ○No ○
  17. Has the child ever suffered injuries to the mouth, head, or teeth? ______Yes ○No ○
  18. Has the child had any problems with the eruption or shedding of teeth? ______Yes ○No ○
  19. Has the child had any orthodontic treatment? ______Yes ○No ○
  20. What type of water does the child drink? ___City water ___Well water ___Bottled water ___Filtered water
  21. Does the child take fluoride supplements: ______Yes ○No ○
  22. Is fluoride toothpaste used? ______Yes ○No ○
  23. How many times are the child’s teeth brushed per day? ______When are teeth brushed? ______
  24. Does the child suck his/her thumb, finger, or pacifier? ______Yes ○No ○
  25. Does the child participate in active recreational activities? ______Yes ○No ○

NOTE: Both doctor and patients are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his staff, responsible for any action they take or do not take because of errors or omissions that I may have make in the completion of this form.

Parent’s/ Guardian’s Signature ______Date ______

Spouse or Responsible Party Information

The following is for: the patient's spouse the person responsible for payment  self


Male Female Married Single Child Other

Social Security #: ______Birth Date:

Phone (Home): ______(Work): ______Ext: ______Best time to call:


Street Apartment #

City State Zip Co

Consent for Services

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 in cash 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 payment of all dental services. This office will help prepare the patients 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 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, upon the discretion of the dentist, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months 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 suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at my office to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

______Date: ______Relationship to Patient: ______

Signature of patient, parent or guardian

______Date: ______Relationship to Patient: ______

Signature of guarantor of payment/responsible party

Dr. Michael Koumas, DDS

Newburgh, NY

Thank you for choosing our office for your dental health care needs. Our primary mission is to deliver the finest, most comprehensive dental care available today with the least amount of discomfort.

We feel that whatever your dental needs may be, from implants, periodontal treatment, bonding, or porcelain veneers, fillings and preventative care, we can satisfy them by performing excellent dentistry within the confines of our office. As a family oriented office we treat and welcome children. Dr. Koumas and our Hygienists are aware of all the latest advances in dentistry, and are active in continuing education courses each year. Dr. Koumas maintains a high profile of well trained dental staff. They are all here to assist you with any questions you may have concerning any aspect of your dental treatment.

One of the major aims of good dental treatment is prevention of future problems. Patients at our office appreciate the benefits of comprehensive examination and continued care. We believe that good planning and follow through will prevent any needless aggravation and pain. Your comforts, both dental and financial, are very important to us. We make every effort to achieve our goal with the best dentistry has to offer.

Insurance and payment of Services

We consider our relationship with you to be of primary importance and will always make our recommendations to you based on what we believe is the best treatment for you regardless of your insurance coverage. We will assist you in any way possible to maximize your dental insurance benefits; however, we have no relationship or responsibility to your insurance company. We will work with your insurance to obtain the best benefits for you. Our office offers a flexible payment program through “Lending Club” which is a revolving charge account that is easy to use, it takes just minutes to apply and is ideal for all treatment costs not covered by insurance. Please inquire at the front desk with any questions.

Cancellation Policy

We respect that your time is valuable to you and we strive to have wait time kept to a minimum at all times. In return we require a 48 hour notice be given in the event you cannot keep your appointment. Failure to do so will result in a minimum of a $25 fee being applied to your account. Please remember, you’re cleaning and check up appointments are the most important aspect of your dental health!

We hope this is the beginning of a gratifying doctor-patient relationship. If we fail in any way to fulfill your expectations, please let us know. Since our practice is built on referrals from satisfied patients, we hope that you will feel the same and let your friends and neighbors know of our office.

Patient Signature ______Date ______

Acknowledgement of Receipt of Privacy Practices Notice

Dr Michael Koumas, DDS

4 Hudson Valley Professional Plaza

Newburgh, NY 12550

(845) 562-1108

Section A: The Patient

Name: ______

Address: ______

Phone #: ______

Section B: Acknowledgement of Receipt of Privacy Practices Notice

I ______, acknowledge that I have received a Notice of Privacy Practices from the above named practice.

Signature: ______Date: ______

If a personal representative signs this on behalf of the individual, complete the following:

Personal Representative’s Name: ______

Relationship to Individual: ______

Section C: Good Faith Effort to Obtain Acknowledgement of Receipt

Describe the effort made to obtain the individual’s signature on this form and describe the reason why the individual would not sign this form:



I attest that the above information is correct

Signature: ______Date: ______


In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, Dr Koumas DDS,PC cannot

release any information regarding you to anyone without your written consent except as set forth in the Act. Please

complete the authorization below, specifying whom Dr Koumas, DDS PC may contact and to whom to release

information with regard to your case. Please return the completed authorization Dr Koumas’ Office. Local

language translations are acceptable to facilitate completion of the form in English.

IMPORTANT: You are not obliged to grant anyone access to information regarding you but failure to

provide the information requested on this form may make it more difficult, or impossible, for the

Dr Koumas’ Office to assist you.

Full Name ______DOB ______

I hereby authorize the office of Dr Michael Koumas DDS PC

to release information regarding me to the following individuals

Name ______Address______Relationship ______

Name ______Address______Relationship ______

Name ______Address______Relationship ______

Name ______Address______Relationship ______

Signature of patient ______Date______

The U.S. Department of State is committed to ensuring that any personal information

received is safeguarded against unauthorized disclosure. The data you provide is subject

to the provisions of the Privacy Act (5 U.S.C. 552a).