NEW PATIENT INTAKE FORM
(with Healthy Kids Dental Program)
PARENT OR LEGAL GUARDIAN INFORMATION
PREGNANCY / NEONATAL HISTORY
INFANCY / CHILDHOOD / ADOLESCENCE HISTORY
Other Medical Conditions:
*** PRE-OPERATIVE GUIDELINES ***
- Nothing to eat after midnight (this includes gum, candy, or anything other than clear liquids)
- Clear liquids (i.e., water, apple juice, Gatorade, 7-Up, or Sprite) can be consumed after midnight, but they must be stopped four (4) hours before the appointment time that was provided to you by the dental office.
*** IMPORTANT NOTIFICATION ***
A Parent or a Legal Guardian must be present and remain at the dental office during the time of service.
HIPAA AND OUR PRIVACY POLICIES
(The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) addresses the manner in which a Patient’s individual health information may be used or disclosed by Covered Entities (as defined in HIPAA) and other individuals and entities, such as a Provider. For more information regarding your rights under HIPAA, please visit their site at https://hhs.gov/ocr/privacy.)
Please initial below that you have read, understood, and acknowledge the following:
I, the undersigned, certify that I have read the above pre-operative guidelines and that the above information is complete and accurate to the best of my knowledge. I understand that providing incomplete or inaccurate information may negatively influence my child’s treatment and treatment results.
CONSENT FOR DENTAL ANESTHESIA SERVICES
The following is provided to inform patients about having treatment under dental anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatments.
I, the undersigned, hereby authorize and request any doctor represented with CarePoint Dental Anesthesia to administer anesthesia to my child as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for my child’s well-being may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:
- Pain and/or bruising at the IV site
- Sore throat and/or hoarseness
- Muscle aches
- Nausea and/or vomiting
- Heart Injury
- Brain damage or death
- Injuries to lips, teeth, mouth or throat from airway instruments or devices
- Unexpected drug reaction
- Infection at intravenous site and veins nearby
- Bleeding/injury in the nose due to passage of a breathing tube
- Lung infection
- Eye injury or infection
- Weakness in breathing after awakening
- Nerve Damage
- Alternative options to deep sedation/general anesthesia have been discussed with me and may include the use of local anesthesia with nitrous oxide sedation or local anesthesia alone.
- I confirm that my child (the patient) has not had anything to eat or drink after midnight (this includes gum, candy, or anything other than clear liquids). Clear liquids (i.e., water, apple juice, Gatorade, 7-Up, or Sprite) can be consumed after midnight, but they must be stopped four (4) hours before the appointment time that was provided to you by the dental office.
- I certify that to my knowledge that my child (the patient) is not pregnant or trying to become pregnant.
- I have read and agree to the HIPAA Notice of Privacy Practices posted on our website www.cpmich.com.
I, the undersigned, consent to the anesthesia deemed appropriate by my child’s anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives, and expected results of the anesthetic plan of care.