WARNING-Carefully Read The Insurance and Consent Form Prior To Dental Care For Your Child.
You may be consenting to strapping down your child for minor dental care.
Here is a copy of the standard paper work filled out prior to treatment I located on the Net. Note the section in red below. After reading over the paper work and it mentioned using restraints, this is one dentist I would have serious reservation about taking my child for dental care. But of course that's just me. He may be a very well trained dentist, I don't know. All I know is in his consent forms, he wants you to sign a consent to strap down your child. This is typical for way too many dentists. What I'm saying is be very careful as to what you are agreeing to have done to your child.
Welcome to Larry Caldwell, DDS
Dentistry for Children
15200 Southwest Freeway, Suite 320
Sugar Land, Texas 77478
(281) 565-5437
Fax: (281) 565-6446
Be sure to complete front and back and bring with you on your first visit. You may mail
them if you like and we can get your insurance verified before your appointment. Please
call if you have any questions.
The packet includes the following:
Welcome Form
Office Policies
Behavior Management Policy
Dental Insurance Considerations Letter
Acknowledgement of Receipt of Notice of Privacy Practices
Tell Us About Your Child
Today’s Date_______________
Name_________________
Last First MI________________
Preferred Name
Male Female (Circle One_
Child’s Birth date ___/___/___ Child’s Age_______________
School Grade_______________
Child’s Home#___________________
Child’s Home Address____________________________________
Apt/Condo#____________
City State Zip________________________________________
Who is Accompanying the Child Today?___________________________
Name_________________________
Relationship_____________________________
Do you have legal custody of this child? Yes No
Is your child adopted? Yes No
How did you hear about our office?____________________
Other family member(s) seen by us___________________________________
Parent’s Marital Status Single Widowed Married Divorced Separated (Circle One)
Primary Dental Insurance_____________________
Insurance Co. Name___________________________
Insurance Co. Address________________________
Insurance Co. Phone__________________________
Group # (Plan, Local or Policy #)__________________________
Insured’s Name___________________________________
Relationship to Patient_________________________________
Insured’s Birth date ___/___/___ SS#___________________________
Insured’s Employer__________________________
Orthodontic Coverage? Yes No
So that we may better serve you, please provide us with an email address:____________
Person Responsible for Account________________________
Name_____________________________
Billing Address____________________________
Work# Ext Home#_________________________
Employer___________________________
DL# SS#_____________________________
Name of Nearest Relative___________________________
Work# Ext Home#________________________
Mother’s Information Step-Mother Guardian
Name__________________________
Work# ________________Ext Home#_______________
Employer___________________________
Cell#_____________________ SS#_____________________
Date of Birth_________________
Father’s Information Step-Father Guardian
Name___________________________
Work# _______________Ext Home#__________________
Employer______________________________
Cell# __________________SS#____________________
Date of Birth____________________________________
We would like to welcome you and your child to our office. Our goal is to make every child’s visit pleasant and educational. Our practice is based on preventive care. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
Welcome
Larry Caldwell, D.D.S.
& Associates
Medical History
Has the child ever had a bad experience with dental work? Yes No
Is the child Delayed Average Advanced in social development? Please circle one.
How would you describe the child’s personality/temperament? Circle all that apply:
Cooperative Uncooperative Sensitive Apprehensive Well-adjusted Aggressive Shy
Previous dentists’ name and phone number_____________________________
Last Date Seen____________________ X-rays_____________________
Is your child’s drinking water fluorinated? Yes No
Is your child taking vitamins with fluoride supplements? Yes No
How many times a day are your child’s teeth brushed?
Is the child currently using a bottle? Yes No How often?
Current dental habits. Please circle:
Thumb or Finger Sucking Use of Pacifier Lip or Cheek Biting Nail Biting
Previous or current TMJ (jaw) pain, tenderness or popping? Yes No
Does the child have or ever had recurring headaches? Yes No
Has the child ever had any of the following medical problems? Please circle all that apply.
Y N Cancer/Tumors Y N Hepatisis
Y N Tuberculosis
Y N Asthma
Y N Rheumatic Fever
Y N Sight Impairments
Y N Congenital Heart Defects
Y N Liver Or Kidney Disorder
Y N Lung or Respiratory Problems
Y N Gastro Intestinal Problems
Y N Convulsions/Epilepsy
Y N HIV/AIDS
Y N Diabetes Y N Endocrine System
Y N Hearing Impairments
Y N Frequent Infections
Y N Hemophilia
History of blood transfusions? Yes No
Date_______________________________
Does the child have a heart murmur or condition that requires Prophylactic Antibiotic coverage for dental work? Yes No
Please list any serious medical problems that the child has had:
Hospitalizations or injuries
Please list all drugs the child is allergic to Other allergies____________________
Please list all drugs the child is currently taking Dose___________________________
Does the child have seizures? Yes No Are the seizures related to high fever? Yes No
Does the child experience an aura before seizure? Yes No
Are the seizures related to high fever? Yes No
Does the child have any behavioral or learning disabilities?
Mental Retardation? Yes No Skill Level____
Handicaps/Physical Disabilities_____________
Any other significant problems or comments
Has the child had any recent infections of bacterial or viral origin? Yes No
Is your child currently under the care of a physician? Yes No
Child’s Physician___________________ Phone___________ Date Last Seen_______
Because your child is a minor, it is necessary that signed permission be obtained from a parent or guardian before any/or all necessary dental treatment is performed. Diagnosis of services needed and financial obligations will be discussed with you by the doctor and/or staff before treatment is rendered.
Your signature authorized Dr. Caldwell and/or his Pediatric Dentist Associate to render necessary dental treatment, to administer anesthetics, to administer medication, to take radiographs (X-rays), clinical photographs, study models and other records necessary for an accurate diagnosis, to utilize behavior management therapy as needed to provide safe dental care for your child and employ such assistance as is appropriate.
Signature of parent or guardian_______________________ Date____________
I verbally reviewed the medical/dental information above with the parent/guardian & patient named herein. Initials_________ Date__________
Doctor’s Comments:
_______________________________________________________
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CEC and the ADA.
Larry Caldwell, D.D.S.
15200 Southwest Freeway, Suite 320
Sugar Land, Texas 77478
Office Policies
The person accompanying the patient is responsible for the account regardless of who carries the insurance on the patient.
We request that the person accompanying the child not leave the premises until the appointment is over, in the event a question arises regarding the child's appointment.
A broken appointment is a loss to everyone. As a courtesy, please allow a 24 hour notice for any schedule changes.
Dr. Caldwell, as a courtesy, will accept and file your insurance for you, HOWEVER, WE ARE NOT A PARTICIPATING PROVIDER ON ANY DENTAL PLANS, THIS MEANS YOU ARE RESPONSIBLE FOR THE DIFFERENCE BETWEEN OUR FEE AND THE INSURANCE ALLOWABLE FEE.
THE ONLY HMO/DMO WE ARE AFFILIATED WITH IS CIGNA (AGE LIMIT IS UNDER 7 YEARS OLD). IF YOU HAVE AN HMO/DMO, THEN YOUR INSURANCE WILL NOT PAY OUR OFFICE.
I am aware that insurance will cover an estimated percentage of most dental procedures and the portion that is not covered by insurance is due at the time services are rendered, unless other financial arrangements have been made prior to the dental appointment.
I am aware that some procedures are subject to a deductible and if it has not been met then I will pay this at the time services are rendered unless other financial arrangements have been made prior to the dental appointment.
If you have secondary insurance (two DENTAL plans), it does not necessarily mean that these combined insurances will cover your services 100%. It is up to you, the insured, to know how the two dental plans will coordinate benefits. We do not file secondary insurance.
I hereby agree to assign all insurance payments to Dr. Larry Caldwell. I am aware that my insurance company may not cover all of the professional fees. I hereby agree to pay, within 30 days, any outstanding balance following payment by the insurance company unless other financial arrangements have been made.
I agree that if the insurance fails to pay Dr. Larry Caldwell within (60) days of the rendering treatment all fees are due and payable at that time.
In the event the insurance company pays you the patient instead of Dr. Larry Caldwell, I agree to forward the payment to
Dr. Larry Caldwell.
In the event a check is returned from a financial institution, a return check fee of $20.00 will be applied.
In the event of default, I promise to pay legal interest on the indebtedness together with such collection costs as may be required to effect the collection of this note.
SIGNATURE:______________________________________ DATE:______________
Larry Caldwell, D.D.S.
15200 Southwest Freeway, Suite 320
Sugar Land, Texas 77478
Behavior Management Policy
Providing quality dental care for children requires expertise in directing child behavior. Our goal is to instill in the child, a positive attitude towards dentistry. Maintaining proper behavior of children while in the dental office demands skill of verbal guidance, prevention of inappropriate actions, and reinforcement of appropriate behavior. These techniques are used only for behavioral modification and not to reprimand or punish a child.
The following are various behavior management techniques used in this office.
•Positive Reinforcement: Social reinforcers such as verbal praise and non-social reinforcers such as rewards (toys, stickers).
•Tell-Show-Do: Explain procedures and instruments to the child with the use of modified terms such as “sleepy juice,” “water whistle,” and “wiggle tooth” rather than “shot,” “drill,” and “pull tooth.”
•Distraction: Use of distraction to divert the patients' attention from what he/she may perceive as unpleasantness.
•Voice Modification: Change of voice volume or tone to gain a child's attention and direct his/her behavior.
•Nitrous Oxide/Oxygen Sedation: This is a very safe and effective conscious sedation method which is easily monitored. The onset of this sedation is quick and recovery is fast and complete before the child leaves the office.
•Pediwrap or Papoose: Partial or complete immobilization with the use of a blanket type wrap, is sometimes necessary to protect the child from injury while using dental instruments. This technique is only used in cases when it has been determined that all other forms of behavior management have not or will not be effective.
It is our office policy to minimize the use of more extreme forms of behavior management techniques and to implement them only when necessary.
SIGNATURE:___________________________________ DATE:_____________
Larry Caldwell, D.D.S.
15200 Southwest Freeway, Suite 320
Sugar Land, Texas 77478
(281) 565-5437
Dear Parent,
We accept and file dental insurance as a courtesy to our patients. We try to know all aspects of your dental plan. Any treatment outline that we present to you is just an ESTIMATE and not a guarantee of benefits.
When we call to verify benefits, the insurance company informs us that, “this is not a guarantee of benefits until they actually receive the claim and process it.”
We file a pre-estimate to your insurance for some procedures such as orthodontic appliances, crowns, surgical procedures and large cases. We do not submit pre-estimates for every procedure but, at your request, we will gladly do so. It normally takes 3 to 4 weeks to receive an estimate back from an insurance company.
In-Network versus Out-of-Network PPO Insurance
When you have a PPO you can go Out-of-Network and the insurance will pay our office. What does this mean? In-Network means that we have a contract with your insurance company and we agree to accept their fees. Out-of-Network means we DO NOT have a contract with your insurance and we do not accept the fee that your insurance allows and you are responsible for the difference between our fee and the allowable fee from your insurance. We will not adjust off the difference between the two.
HMO/DMO Insurance
When you have an HMO/DMO, then you have to go to a doctor that accepts your insurance; you cannot go Out-of-Network. The only HMO/DMO that we are on is CIGNA (age limit is under 7 years).
It is very beneficial, as the insured, to know your dental plan.
Common questions to Ask Your Insurance Company
• What is the frequency of exams, cleanings and fluoride?
• Is there an age limit for fluoride treatments?
• Are sealants a covered benefit? If so, what is the age limit?
• Do I have orthodontic benefits?
• Do you have a waiting period with your insurance plan?
Most insurance companies will tell you how they will cover a procedure if you give them the ADA code, which is on the treatment outline.
SIGNATURE:_________________________________ DATE:___________
Larry Caldwell, D.D.S.
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgment**
I, _______________________________________, have received a copy of this office's Notice of Privacy
Practices
________________________________________
Please Print Name
________________________________________
Signature
________________________________________
Date
For Office Use Only
We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the acknowledgment
An emergency situation prevented us from obtaining acknowledgment
Other (Please Specify)
