New Patient Form

Thank you for taking time to register. This will save a good amount of time with your visit. Please let us know if you have any questions.

PATIENT DETAILS

Does the child have a preferred name to be called by?
Mother's Details
Only one primary legal guardian is needed
City of Residence
State of Residency
Zip Code
Father's  Details
Only one primary legal guardian is needed
City of Residence
State of Residency
Zip Code

INSURANCE DETAILS

Does your child have dental insurance or Medicaid coverage?

Person named on the policy
Click or drag a file to this area to upload.

HEALTH DETAILS

Is your child in good health? *
Does your child have regular medical exams? *
Is your child up-to-date with immunizations? *
Is your child presently taking medicine? *
Has your child experienced any unfavorable or allergic reaction to medicine? *
Such as Penicillin, Aspirin, or Xylocaine
Has your child been hospitalized since birth or had outpatient surgery? *
Check any of the following that pertain to your child's health history

Please review your details before submitting to ensure accuracy. Thank you for taking time to register online with us!

Dr. Kenneth W. Johnson and his staff are committed to providing your child with the best possible care. Dr. Johnson adheres to the guidelines recommended by the American Academy of Pediatric Dentistry and the American Dental Association for his treatment recommendations for your child. Since your child is a minor, it is necessary that signed permission be obtained from the parent/guardian before any dental services can be performed by Dr. Johnson and/or associates. Authorization is granted by signing below.

As dental care providers, our relationship is with you, not your insurance company. The fact that your insurance chooses not to cover a certain dental procedure does not mean that the procedure is not important to your child.

Generally, a way in which your employer seeks to minimize the cost of insurance is by eliminating coverage of certain dental procedures, even though they are necessary in providing the best dental care for you child.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry our 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. 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 your protected health information that we maintain.

By signing this Consent, 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 form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

You will have the right to revoke this Consent at any time by giving us written notice of your revocation. 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 your child or to continue treating your child if you revoke this Consent.

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize as may be necessary for proper dental care. I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits my pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or part by my dental care payor.

Dental Visit Details

WHO WILL ACCOMPANYING YOUR CHILD TO THEIR VISIT TO OUR CLINIC?

It is our policy to require a parent or legal guardian to be present at the initial visit. Please let us know the name of the person who will be bringing your child.