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					                                      Michael A. Crist, D.D.S., P.C.
                            Specialist in Pediatric Dentistry & Orthodontics
                           Welcome to our practice! Please complete this form front and back.

Patient’s Name: ______________________________________________________________________________________
                            Last                     First                      Middle Initial            Call name
Patient Address: ______________________________________________________________________________________

        ________________________________________________________________Age:______________________
                            City                     State              Zip
Phone Number: ___________________________________________ Patient Date of Birth: _____________________
Patient Medical History: (circle all that apply)

Heart Murmur                          Congenital Heart Defect           Cancer                   Abnormal Bleeding
Diabetes                              Rheumatic Fever                   HIV/ AIDS                Any Operations
Asthma                                Hepatitis                         Tuberculosis             Any Stays in Hospital
Convulsions/Epilepsy                  Hearing Impairment                Hemophilia               Handicaps/Disabilities
Kidney/Liver Problems                 Headaches                         Prosthesis               Allergies to Any Drugs
History of Scarlet Fever              Food Allergies                    Latex Allergy

Please discuss any serious medical problems that the child has/had or other medical information that may apply:
____________________________________________________________________________________________________

**Does the patient need antibiotic medication prior to a cleaning? Yes/ No
**Is the Patient Pregnant? Yes/ No
***Has the patient tested positive for AIDS or HIV? Yes/ No

Account Information:
Who is with the child today? Name:_______________________________________________________________
Billing Address: _______________________________________ Home Phone#: _____________________________
        __________________________________________________________________________________
                            City                     State                                Zip
Relationship to Patient: _____________________                  Do you have legal custody of this child? Yes/No

Father’s Information: Name: ____________________________________Home #_______________________________
Employer: ___________________________________________________ Work #: ______________________________
Date of Birth: _________________ Social Security #__________________ Texas License #________________________

Mother’s Information: Name: ____________________________________ Home #_______________________________
Employer: _____________________________________________________ Work #: _____________________________
Date of Birth: _________________ Social Security #___________________ Texas License #_______________________

Insurance Information:
Name of Insurance Carrier: ____________________________________ Group/Policy #: _________________________
Insurance Carrier Address: ____________________________________________________________________________
___________________________________________________Insurance Phone Number: __________________________
Name of Insured Employee: ____________________________________ Relationship to Patient: ___________________
Insured Date of Birth: ___________________Insured’s Employer: ____________________________________________
Social Security Insured: _________________________ Insured Marital Status: _________________________________
I understand the information that I have given is correct to the best of my knowledge, that it will me held in the
strictest confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I also
authorize the dental staff to perform the necessary dental services my child may need.

_________________________________________________ Date: _____________________
        Signature Parent/legal guardian
                                    Michael A. Crist, D.D.S., P.C.
                            Specialist in Orthodontics & Pediatric Dentistry
Welcome to our office!!! We are committed to providing you with the best possible care.
(Please read and initial each line)
______Payment for services is due at the time services are rendered unless arrangements have been approved in
advance by our staff. We accept checks and most major credit cards.
______The parent/legal guardian who accompanies the child is responsible for payment at the time of service unless
prior arrangements have been approved.
______If you have an insurance plan, we will be happy to assist you in claiming your benefits. Please provide us with
a completed dental claim form and a copy of your dental insurance card.
______Insurance policies and payment programs can be confusing; we require that patients contact their insurance
company to confirm that their assumptions regarding coverage for dental treatment are correct. Please request this
information in writing from your insurance company. Patients must realize that professional services are rendered to
a person, not an insurance company. The insurance company is responsible to the patient and the patient is
responsible to us. We cannot render services on the assumption that the charges will be paid by an insurance
company. However, we will help in any way we can.
______Returned checks will result in a $30.00 charge to your account.
______Any cost associated with the collection of payment for services rendered will be paid by the responsible party.
Accounts with balances older than 90 days may be subject to additional collection fees and interest charges of 1.75%
per month.
______24 hours notice is required to cancel an appointment. Missed appointments will result in a Charge of $35.00.
______Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the
CDC and the ADA. I understand that all State and Federal OSHA regulations are strictly adhered to.
______Our office limits all pediatric dental appointments to Saturday due to an existing full-time orthodontic
practice. Weekday appointments are limited to emergencies.

Please feel free to ask our staff any questions you may have regarding the above information. We are here to help
you.
______I, as the Responsible Party, acknowledges that I have reviewed the above information and that I understand it
completely.

__________________________________                               __________________
       Parent/Legal Guardian                                       Date
  FOR OFFICE USE ONLY**** FOR OFFICE USE ONLY**** FOR OFFICE USE ONLY****

1. Date: _____________ Comments: ______________________________ Parents:
____________________________________
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ________________ Date: ____________________ Dr Comments:
____________________________________________

1. Date: _____________ Comments: ______________________________ Parents:
____________________________________
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ________________ Date: ____________________ Dr Comments:
____________________________________________

1. Date: _____________ Comments: ______________________________ Parents:
____________________________________
I verbally reviewed the medical/dental information with the parent/guardian& patient named herein.
Initials: ________________ Date: ____________________ Dr Comments:
____________________________________________
                                           Michael A. Crist D.D.S.
                                  Specialist in Orthodontics & Pediatric Dentistry

      CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT/PARENT GIVING CONSENT

Patient Name: ________________________________________________________________________________________

Address: ____________________________________________________________________________________________

Telephone: ____________________________ Parent email: ___________________________________________________

Parent Name: __________________________________________ Parent Social Security #:___________________________


SECTION B: TO THE PATIENT/PARENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information
to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy practices before you decide whether to sign
this Consent. Our Notice Provides a description of our treatment, payment activities, and healthcare operations, of the uses
and disclosures we may make of your protected health information, and of other important matters about your protected
health information. A copy of our Notice is available upon request at the reception desk. We encourage you to read it
carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our
privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may
apply to any of our protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

                                              Michael A. Crist, DDS
                                          13303 Champion Forest Dr. #10
                                             Houston, Tx 77069-2650
                                                  281-444-1735
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation
submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we
took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue
treating you if you revoke this Consent.
SIGNATURE

I, _______________________________________________, have had full opportunity to read and consider the contents of
this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my
consent to your use and disclosure of my protected health information to carry out treatment, payment activities and
healthcare operations. I have received a copy of this office’s Notice of Privacy Practices.

Parent Signature: ________________________________________________ Date: _______________________________

Relationship to Patient: _____________________________
                                                    Insurance Information

If you have an insurance plan that pays dental benefits, we will be happy to assist you in claiming your benefits. With
increasing numbers of dental insurance programs, we find it impossible to have a complete and accurate knowledge about all
of these programs and our individual patient's status with respect to his own program. Please be advised that our office does
not participate in discount dental programs, HMO or DMO plans for pediatric dentistry. In order to process your insurance
claim properly, we will need the following information and a copy of your dental insurance card.

Patient Name: ______________________________ Date of Birth: _____________________________
Address: ___________________________________________ Phone: __________________________
City/State/Zip: ______________________________________________________________________
Relationship to Insured Employee: Child / Spouse / Self / Other Sex: Male / Female

Insured Employee Information: Primary insurance
Name: ____________________________________ _______________Date of Birth: ____________________________
Social Security# or Insurance ID# :_______________________________________________(required)
Address: ________________________________________________________________________________________
City/State/Zip: ___________________________________________________________________________________
Employer Name: _______________________________________________ Group #:___________________________

Insurance Company Name: __________________________________ Phone Number: #:_____________________________
Claims Mailing Address: ________________________________________________________________________________

____________________________________________________________________________________________________

Is Patient Covered by another insurance plan? Yes / No

Insured Employee Information: Secondary insurance
Name: _______________________________________________ Date of Birth: ___________________________________
Social Security# or Insurance ID# :__________________________________________________________( required)
Address: _____________________________________________________________________________________________
City/State/Zip: ________________________________________________________________________________________
Employer Name: ____________________________________________ Group #:__________________________________

Insurance Company Name: __________________________________ Phone Number: #:_____________________________
Claims Mailing Address: ________________________________________________________________________________

____________________________________________________________________________________________________
I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials
not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or
a portion of such charges. To the extent permitted under applicable law. I authorize release of any information relating to this claim.

X______________________________________________________________________________________________________________
        Signed (Patient/Guardian)                                               Date (MM/DD/YYYY)

I hereby authorize payment of the dental benefits otherwise payable to me directly to Michael A Crist D.D.S:

X______________________________________________________________________________________________________________
        Signed (Patient/Guardian)                                               Date (MM/DD/YYYY)

Insurance policies and payments can be confusing; we require that patients contact their insurance company to confirm that
their assumptions regarding coverage for dental treatment are correct. Please request this information in writing from your
insurance company. Patients must realize that professional services are rendered to a person, and not an insurance company.
The insurance company is responsible to the patient and the patient is responsible to us. We cannot render services on the
assumption that the charges will be paid by an insurance company. However, we will help in any way we can.
                                Michael A. Crist, D.D.S.
                   Specialist in Orthodontics and Pediatric Dentistry
                            13303 Champion Forest Dr #10
                                  Houston, TX 77069
                                     281-444-1735
Patient Name: ___________________

Appointment Date/Time: ___________________________________

				
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