925-443-5980

1964 Fourth St.

Livermore, CA 94550

Facebook
Google+
Instagram
Yelp
Angie's List

{1}

##LOC[OK]##

Home
Office
Patient
Treatment
Contact Us

Home
Office
Patient
Treatment
Contact Us

New Patient Registration Form

Skip Sidebar Navigation

Last item for navigation

EastBayPediatricDental.com New Patient Registration Form

Patient Information

* Patient First Name: (Required)

Patient Middle Name:

* Patient Last Name:

Preferred Name:

Gender: Male Female

Birth Date:

Age:

* Home Address:

City:

State:

Zip:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Pets (name & type):

Is child adopted? Yes No

Does child know they are adopted? Yes No

How did you hear about our practice? Ad Internet Family/Friend Physician/Dentist Other (share below)

Name of person/doctor/other who referred you:

Have we treated any other family members? Yes No (If yes, please share)

Name & Relation to Patient:

Dental History

Is this your child's first visit to the dentist? Yes No

If no, name of previous dentist:

Dentist Phone Number:

Date of last visit:

Were X-rays taken? Yes No

How was your experience:

Does your child brush their teeth? Yes No

How often?

Does your child brush with adult supervision? Yes No

Does your child floss? Yes No

How often?

Does your child take a fluoride supplement? Yes No

Is your water fluoridated? Yes No

Does your child use a fluoride toothpaste? Yes No

Reason for Dental Visit/Any Dental Concerns:

Does your child have any special needs?

How can we make this a positive experience for your child?

Have your child's tonsils or adenoids been removed? Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Does your child have any missing or extra permanent teeth? Yes No

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

If so, explain:

Does your child have speech problems? Yes No

If so, explain:

Does your child currently, or has your child ever, had a history of: Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem Pacifier Nursing Bottle Feeding Snoring

Medical History

Is your child currently being treated by a pediatrician? Yes No

Pediatrician Name:

Last Physical:

Phone:

Does your child have any allergies/sensitivities to medications, food, or latex? Yes No

If yes, please list:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has your child had any serious illnesses or operations? If yes, describe:

Check if your child has or has ever had any of the following: ADD/ADHD Anaphylactic Allergy Response Anemia Anxiety Arthritis, Rheumatism Artificial Heart Valves Asthma Autism Bladder Disorder Blind/Diminished Vision Blood Disease Bone Disorder Brain Injury Bruising Cancer Cerebral Palsy Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Cystic Fibrosis Deaf/Hard of Hearing Depression Developmental Delay Diabetes Down's Syndrome Eating Disorders Earaches/Infections Emotional/School Issues Epilepsy Fainting Growth Delay Headaches/Migraines Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Immune Disorder Kidney Disease Liver Disease Mitral Valve Prolapse Muscular Disorder Premature Birth Radiation Treatment Respiratory Disease Rheumatic Fever Shortness of Breath Sinusitis Skin Rash Thyroid Problems Tonsilitis Tuberculosis

Parent / Guardian Information (Self)

*Please note: Areas are provided for insurance details following BOTH 'Parent' & 'Co-Parent' sections of this form. This section pertains specifically to the person who is completing this form; this is the person who will sign and submit it.

First Name:

Last Name:

Marital Status: Single Married Divorced Widowed Significant Other

Relation to Patient: Mother Step-Mother Father Step-Father Guardian Other

If other, please specify:

Birth Date (MM/DD/YYYY):

Social Security Number:

Financial Policy: Without the SSN of the responsible party completing this form, the patient will be required to pay for all services in full at the time of the visit. We will provide you with completed insurance forms to be mailed in by you, directing all claim reimbursement to be mailed directly to the policyholder.

I acknowledge and understand the above policy: Yes

Address (if different than patient's):

City:

State:

Zip:

* Primary Phone:

Phone Type home cell work

Secondary Phone:

Phone Type home cell work

E-mail:

Dental Insurance Information

*Please note, most companies provide medical and dental insurance through different insurance companies; please be sure to provide information pertaining to your dental insurance. Necessary information for us to submit a complete claim on your behalf is: Primary Policy Holder Name, Address, Birthday, SSN or Member ID, Insurance Company Name, and Employer (if applicable). We can usually use this information to determine your group number if you need assistance.

Employer:

Occupation/Job Title:

Dental insurance coverage is provided through: Employer Individual Policy Union N/A

If provided through a union, please provide union name and local #:

Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Parent / Guardian Information (Spouse/Co-Parent)

First Name:

Last Name:

Marital Status: Single Married Divorced Widowed Significant Other

Relation to Patient: Mother Step-Mother Father Step-Father Guardian Other

If other, please specify:

Birth Date (MM/DD/YYYY):

Social Security Number:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type home cell work

Secondary Phone:

Phone Type home cell work

E-mail:

Dental Insurance Information

Employer:

Occupation/Job Title:

Dental insurance coverage is provided through: Employer Individual Policy Union N/A

If provided through a union, please provide union name and local #:

Dental Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Emergency Contact / Additional Caregiver Information

Person, other than parent or guardian, that you allow us to release appointment or medically-related information to regarding your child.

Emergency Contact First Name (other than parent):

Emergency Contact Last Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Authorization

The permission of a parent or guardian is necessary for dental treatment of a minor. I give the permission to use such measures as deemed necessary in Dr. Patrick C. Creevan's professional judgement to render the best dental treatment for my child. I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's health status or contact information. I have also received a copy of "The Facts About Fillings" as required by law (available for review and/or download on eastbaypediatricdental.com).

Submitted by:

Date:

Financial Agreement

Patients with dental insurance must provide accurate and complete insurance information so we may assist you in filing your claim promptly. If you have provided the office with your SSN, you will be required to pay only the patient portion as dictated by your insurance plan on the day of dental treatment. If you prefer not to provide your SSN you will be required to pay for all services in full on the day of dental treatment. The office will assist you in filing your insurance claim by providing you with a completed claim form for you to mail. This form will direct all insurance reimbursement payments to be sent directly to you.

I hereby authorize the dentist to release any information including diagnosis and records to the third party payor and/or other health care practitioners. I authorize and request my insurance to pay directly to the above named dentist, otherwise payable to me but not to exceed the charges shown on the claim. I understand I am financially responsible for any charges not covered by my insurance or by this authorization, I realize that the failure to keep this account current may result in the dentist unable to provide additional dental services except for dental emergencies, or where there is a prepayment for additional services; and where appropriate, a credit bureau report may be obtained.

When insurance coverage is not provided for the patient, payment in full is expected at the time of dental service. When this is not possible, financial arrangements must be made in advance.

As a cash-pay family you may opt to receive a statement of your account balance, payable within 30 days of services rendered, however, the social security number of the party completing this form must be provided. This policy may be subject to change depending on timely account payment.

A $75 Missed Appointment fee may be charged to your account for appointments that missed or cancelled with less than 48 hours.

I realize that the failure to keep this account current may result in the dentist being unable to provide additional dental services, with the exception of dental emergencies for a period of up to 90 days after an account becomes delinquent; or where there is pre-payment for additional services. Where appropriate, a credit bureau report may be obtained.

Submitted by:

Date:

Security Measure

google recaptcha

Dr. Patrick C. Creevan

Dr. Patrick C. Creevan - 1964 Fourth St., Livermore, CA 94550 Phone: 925-443-5980 Email: [email protected]