Patient Form

You may access the following form to assist us with your care. Please complete the following form, and click the "Submit" button at the bottom of the form.

*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection and are HIPAA compliant.

Child Registration Form - Dental

Patient Information


 




Parent / Guardian Information

Parents' Marital Status


Emergency Contact Information

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information




Dental History

How did you hear about our Practice?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply)?





Medical History

Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.



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Drs Johnston, Richardson & Cloud

  • Drs Johnston, Richardson & Cloud - 1610 W. C Place, Russellville, AR 72801 Phone: 479-968-8338 Fax: 479-968-1688

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