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6071EAST WOODMEN ROAD,SUITE 200●●●● COLORADO SPRINGS,CO80923●●●● (719)638-7673(RMPD)

Letter of Welcome

Dear Parent:

Welcome! It is our pleasure to welcome you and your child to our practice. We have three

pediatric dentists and a team of qualified staff to serve your family. Dr. Andrea D’Addario is

originally from Kentucky and received her doctorate of medical dentistry from the University of

Kentucky. Her pediatric residency was completed at Rainbow Babies and Children’s Hospital in

Cleveland, Ohio. After spending most of her childhood in Michigan, Dr. Janelle Tonn attended

dental school at Loma Linda University and pediatric residency at Yale – New Haven Hospital in

Connecticut. Dr. Ashley Killin was born and raised right here on the Front Range of Colorado.

She attended dental school at University of Louisville. She completed her pediatric residency at

Riley Children’s Hospital in Indianapolis. We choose to work with children because a child with

a healthy mouth has great potential to achieve a healthy mouth as an adult. Therefore, everything

we do is designed to make every visit a valuable growing experience. Dental visits can be

frightening for some children, just as it is for many adults. But if all of us will be patient and

understanding, we can help your child avoid and overcome most dental fears. So, a few days

before your appointment, talk with your child about the visit in the same manner that you would

talk to him or her about going to school. Avoid phrases like “the doctor won’t hurt you” or “it

won’t hurt”. Also, avoid words like “shot”, “drill”, and “needle”. Suggest to your child to think

about trying to help even when some procedures may be difficult. If your child cries, do not be

disappointed in your child, yourself, or us. This is a common response to a new and different

situation. We will give your child a lot of praise and TLC.

Every visit is unique, but here is what you can expect with your child’s first visit. After the

receptionist greets you, a dental assistant will meet you in the reception room and guide you and

your child through the visit. The visit will last a little under an hour. Your dental assistant will

“introduce” your child to our friends, Mr. Thirsty (oral suction), Mrs. Vacuum, and others. We

will tell them what the equipment is, show them how it works, and demonstrate how we do it.

Then we may take “pictures” of your child’s teeth with Mr. Camera (x-rays) and film paper to

bite on. While your child is lying down, the doctor will “count” your child’s teeth. Your dental

assistant will clean your child’s teeth and apply fluoride. If further treatment is needed, it will not

start until the second appointment. You and your child will learn how new behaviors (preventive

procedures and eating choices) will improve their oral health.

Parents are encouraged to accompany their child throughout the visit, particularly as we discuss

which treatments and behaviors we must work on. We have two office locations for your

convenience. Our Colorado Springs office is located in the NorthCare building attached to the St.

Francis Medical Center. Our Monument office is located at Hwy 105 and Knollwood Dr. If you

need to change your appointment, please notify us at least 48 hours in advance so that someone

else can use your spot. Please fill out and bring with you, the enclosed health history and new

patient information forms. You as the child’s parent or guardian must sign the form. If your

child has seen another dentist, please have that dentist forward us your child’s x-rays. Please

bring your insurance card and any needed co-pay with you. We are excited to meet you and your

child. We appreciate you including us in your child’s oral health. Please contact us if you have

any questions.

Warmly yours,

The Doctors and Staff of

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N

EW

P

ATIENT

I

NFORMATION

(Please Print)

Y

OUR

C

HILD

S

I

NFORMATION

:

First Name: Last Name: Preferred Name:

Date of Birth: Social Security #: Sex:

o

M

o

F

Student?

o

Full

o

Part School Name:

Emergency Contact: Phone:

Who referred your child? Dentist: Orthodontist: Physician:

¡ Other _____________________

o

Friend

o

Phone Book

o

Insurance Company

o

Web

R

ESPONSIBLE

P

ARTY

:

First Name: Last Name: Date of Birth:

Mailing Address:

CITY STATE ZIP

Street Address (if different):

CITY STATE ZIP

Email:

Home Phone: Work Phone: Mobile Phone:

Employer: Occupation: Social Security #:

Relationship to patient: Marital Status:

o

Single

o

Married

o

Divorced

o

Widowed

o

Separated Do you have legal custody of this child? ¡ Yes ¡ No If NO, who has legal custody?__________________________________________

I

NSURANCE

(

PLEASE PRESENT MEDICAL

/

DENTAL CARDS FOR PHOTOCOPY

):

PRIMARY COMPANY: SECONDARY COMPANY:

Insurance Name: Insurance Name:

Insurance Address: Insurance Address:

Group #: ID #: Group #: ID#:

Policyholder: Policyholder:

Address: Address:

Insurance Phone: Date of Birth: Insurance Phone: Date of Birth:

o

Medical

o

Dental

o

Auto Other:

o

Medical

o

Dental

o

Auto Other:

C

ERTIFICATION OF

I

NFORMATION

:

We make every effort to keep the cost of your surgical care down. Payment arrangements can be made with our Financial Coordinator depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you. If you have medical and/or dental insurance, we will be glad to file a claim on

your behalf. Please complete the insurance section above.

Please remember that insurance is considered a method of assisting in the cost of care and is not a guarantee of payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance and any other balance not paid by your insurance company. Past due balances are subject to a monthly finance charge. If your account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, you will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs. This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the provider named on the insurance benefits form unless otherwise stated payable to me.

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P

ATIENT

H

EALTH

H

ISTORY

(Your responses are for our records only & are considered strictly confidential)

Child’s Name: Date of Birth: Age: Height: Weight:

Child’s Physician: Ph: Orthodontist: Ph:

MEDICAL HISTORY:

Is your child presently under a physician’s care, or has been during the past 5 years including hospitalizations and ER visits? Yes No If yes, please explain.

Yes No

¡ ¡ Rheumatic fever? ¡ ¡ Rheumatic heart disease? ¡ ¡ Heart murmur/Heart trouble? ¡ ¡ Congenital heart defect ¡ ¡ Bleeding problems? ¡ ¡ Sickle cell trait? ¡ ¡ AIDS/HIV?

¡ ¡ ARC (AIDS related complex)? ¡ ¡ Anemia?

¡ ¡ High blood pressure?

Yes No

¡ ¡ Mentally challenged? ¡ ¡ Kidney disorders? ¡ ¡ Asthma?

¡ ¡ Hearing/Speech Impairment? ¡ ¡ Developmental delay? ¡ ¡ Diabetes?

¡ ¡ Hepatitis? ¡ ¡ Leukemia?

¡ ¡ Epilepsy (convulsion or fits)? ¡ ¡ Bruise or have frequent nose bleeds?

Yes No

¡ ¡ Do wounds or cuts heal slowly? ¡ ¡ Scarlet fever?

¡ ¡ Tuberculosis? ¡ ¡ Fainting or dizziness? ¡ ¡ Thyroid or gland problems? ¡ ¡ Liver disease?

¡ ¡ Treatment for cancer? ¡ ¡ Frequent colds?

¡ ¡ Birth defects/malformations? ¡ ¡ Immunizations up to date?

Please list any other Medical Condition not listed above:

Please list any and all Medications that your child is presently taking (antibiotics, pain medication, heart medicine, vitamins):

ALLERGIES:

Yes No Reaction: Yes No Reaction:

¡ ¡ Local anesthetics (lidocaine) ¡ ¡ Codeine/narcotics ¡ ¡ General anesthetics ¡ ¡ Penicillin, Sulfa Drugs

¡ ¡ Aspirin ¡ ¡ Latex

¡ ¡ Soy, nuts or eggs ¡ ¡ Others (please list):

DENTAL HISTORY:

Has your child had any accidents involving the teeth or jaws? Yes No Date: If yes, please explain.

Does your child have or do any of the following?

Yes No Yes No Yes No Yes No

¡ ¡ Thumb or finger sucking ¡ ¡ Gritting or grinding teeth ¡ ¡ Tongue thrusting ¡ ¡ Mouth breathing ¡ ¡ Missing teeth

¡ ¡ Extra teeth ¡ ¡ Impacted teeth ¡ ¡ Tumors or cysts of jaws ¡ ¡ Deformed or discolored teeth

Please check all words which seem best to describe your child or adolescent:

¡ Calm ¡ Healthy ¡ Friendly ¡ Cooperative ¡ Spoiled ¡ Talkative ¡ Active ¡ Compulsive ¡ Shy ¡ High strung ¡ Moody ¡ Sickly ¡ Suspicious ¡ Temper ¡ Fearful ¡ Defiant

SURGICAL HISTORY:

List any previous surgeries or procedures that your child has had:

Nausea & Vomiting? Yes No Malignant Hyperthermia? Yes No Family History of Anesthesia Complications? Yes No Prolonged Bleeding? Yes No Blood Transfusion? Yes No If yes, please specify:

HEALTH INFORMATION CERTIFICATION:

The permission of a parent or guardian is necessary for dental treatment of a minor. I give Rocky Mountain Pediatric Dentistry, the doctor, assistant and/or other staff and colleagues, permission to use such measures as deemed necessary in their professional judgement to render a diagnosis for my child. This would include an oral examination, radiographs (x-rays), and other diagnostic aids. I have given a complete, true and accurate report of my child’s physical and mental health history. I have also reported any prior allergic reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my child’s health or any other physical conditions that my child’s medical doctor has advised me should be reported to a dentist.

SIGNATURE: DATE: RELATIONSHIP TO THE PATIENT: DOCTOR SIGNATURE: DATE:

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CONSENT FOR DENTAL TREATMENT

I understand that DENTAL TREATMENT is associated with inherent risks, including, but not limited to, the following:

1. Injury to the nerves as a result of local anesthesia: This would include injuries causing numbness of the lips, the tongue, or other tissues of the mouth or face. This numbness is usually of a temporary nature, but permanent numbness is a possibility. If numbness persists more than 24 hours post-operatively, please call our office.

2. Soreness of the gums: Temporary soreness may result from the placement of a rubber dam, or any restoration that extends below the gumline (e.g. stainless steel crowns). This soreness usually resolves within 48 hours.

3. Sensitivity of the teeth: Placement of any dental restoration can result in a tooth that is sensitive to hot and/or cold. If these symptoms persist for more than a few weeks, it may be an indication that further treatment is necessary.

4. Breakage, dislodgement, or bond failure: Due to the fact that teeth are subjected to extreme forces from chewing, grinding, and possible dental trauma, it is possible that bonded restorations (white fillings) or even amalgam restorations (silver fillings) can be fractured or dislodged, resulting in leakage, recurrent decay, or infection. The dentist has no control over the forces to with the tooth/restoration are subjected.

5. Aesthetics: Although dental materials are constantly improving, it is possible that bonded restorations may wear down, lose their luster, or discolor. The dentist has no control over these factors.

6. For dental extractions:

o

Bleeding, bruising, or swelling: bleeding may persist for several hours. If profuse, please call our office. Some swelling is normal, but if severe, please call our office. Bruising may persist for some time, but generally heals uneventfully.

o

Injury to adjacent teeth or restorations: This is a possibility no matter how carefully the surgery

is performed.

o

Infection: Due to the non-sterile nature of the mouth, or perhaps due to an existing infection,

post-operative infection is a possibility. Some infections can be very serious. If severe swelling occurs, particularly if associated with fever or malaise, please call our office as soon as possible.

7. For endodontically treated teeth:

o

Pulpotomies: In a small percentage of cases, the patient’s body “rejects” the nerve treatment,

resulting in a failed pulpotomy and the need for extraction. The dentist has no control over the body’s biological response to treatment.

o

Pulpectomies: For teeth requiring a pulpectomy, the long term prognosis is guarded. A significant

percentage of pulpectomized primary teeth (baby teeth) will ultimately need to be extracted. This treatment is generally used when short term retention of a primary tooth is important to long term dental health.

8. IT IS MY RESPONSIBILITY TO SEEK ATTENTION SHOULD ANY COMPLICATIONS OCCUR POST-OPERATIVELY AND I SHALL DILIGENTLY FOLLOW ANY INTSRUCTIONS GIVEN TO ME BY THE DENTIST.

9. For those children receiving nitrous oxide analgesia: Potential side effects include dizziness, nausea, and vomiting.

Parents in the treatment room: For most treatment, you may choose whether or not you accompany your child to the treatment room for his/her appointment. Although we are sensitive to the fact that you may have more than one child and that more than one family member may want to participate, we ask that only one adult, and no siblings come to the back. Our goal is to not only provide the highest quality of care but also to effectively communicate with you and your child to provide as much dental education as possible. This is very difficult if both you and your child are distracted by other siblings or when a child is trying to get the attention of both of their parents at the same time. If your child is receiving treatment with oral conscious sedation, parents are asked to remain in the lobby during treatment. This is the only time parents may not accompany their child during treatment and is solely for emergency preparedness, due to the increased level of medical attention and monitoring required.

INFORMED CONSENT: I will be given the opportunity to ask questions regarding the proposed treatment and will be given associated costshare estimates. The doctor will discuss alternatives to this treatment, including the option of rendering no treatment. I understand and assume any and all risks associated with the procedures, and I understand that no guarantees can be made regarding the outcome of the treatment. By signing this form, I acknowledge receipt of risks and limitations associated with pediatric dental procedures.

________________________________________________________________________________________________ Patient’s Name (please print) Parent/Guardian’s Name

________________________________________________________________________________________________ Date Parent/Guardian’s Signature

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Rocky Mountain Pediatric Dentistry, PC

6071 E Woodmen Road | COLORADO SPRINGS CO, 80923 | (719) 638-7673 1415 Cipriani Loop | MONUMENT, CO 80132 | (719) 638-7673

Thank you for choosing Rocky Mountain Pediatric Dentistry. Our primary mission is to deliver

the best and most comprehensive dental care available for your child. An important part of

the mission is making the cost of optimal care as easy and manageable for our families as

possible by offering several payment options.

Payment Options:

You can choose from:

- Cash, Check, Visa, Mastercard or Discover Card

- NO INTEREST¹ Payment Plans² from CareCredit

o

Allow you to pay over time with NO INTEREST¹

o

Convenient, low monthly payment plans² also available

o

No annual fees or pre-payment penalties

Payment is expected at the time services are rendered.

For patients with dental insurance we are happy to work with your carrier to maximize your

benefit and directly bill them for reimbursement for your child’s treatment.³ Estimated patient

cost shares are due at the time of service. Please remember that insurance is considered a

method of assisting in the cost of care and is not a guarantee of payment. Some companies

pay fixed allowances for certain procedures and others pay a percentage of the charge. It is

your responsibility to pay any deductible amount, co-insurance and any other balance not

paid by your insurance company. Past due balances are subject to a 1.5% monthly finance

charge. If your account becomes delinquent, it may be forwarded to an outside collection

agency without notice. If this happens, you will be responsible for all costs of collection,

including but not limited to interest, rebilling fees, court costs, attorney fees, and collection

agency costs.

Rocky Mountain Pediatric Dentistry charges $30 for returned checks.

Scheduling Appointments:

We respect the importance of your time and work very hard to schedule appointments that

accommodate the busy scheduling needs of our families. In return, we ask that parents

make every effort not to change their child’s reserved dental appointments. Broken or

missed appointments create a problem for those patients who are in need of our services.

Therefore, we require 24-hour cancellation notice for any appointment changes that may

occur. A charge of $50 per scheduled appointment will be applied for non-notification in this

matter. In addition, arriving more than 15 minutes late to your appointment may make it

necessary that the appointment be rescheduled.

If you have any questions, please do not hesitate to ask.

Parent or Guardian Signature

Date

Patient Name(s) (Please Print)

¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.

²Subject to credit approval

³However, if we do not receive payment from your insurance carrier within 90 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

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PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my child’s protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

Ø

Treatment (including direct or indirect treatment by other healthcare

providers involved in my treatment);

Ø

Obtaining payment from third party payers (e.g. my insurance company);

Ø

The day-to-day healthcare operations of your practice

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Date:________________

Print Patient Name(s):_______________________________________________ Print Name and Relationship to Patient:_________________________________ Signature:_________________________________________________________

Rocky Mountain Pediatric Dentistry, PC

6071 E. Woodmen Rd, Suite 200 1415 Cipriani Loop Colorado Springs, CO 80923 Monument, CO 80132

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Photo Release Form

We are

proud

of our friends and patients at Rocky Mountain Pediatric Dentistry! We love to

share our accomplishments, activities and good news on our website and FaceBook page.

The law requires that we ask for your permission to use information about your child.

Pursuant to that law, we will not release any personally identifiable information about

you or your child such as last name, address, phone number or email address.

ü

Please check one of the following options

:

o

I

grant

permission for the listed patient(s) photo/image and first name to be

published on the company’s website and/or FaceBook page.

o

I

DO NOT grant

permission for the below listed patient(s) photo/image to be

published on the company’s website and/or FaceBook page.

By signing below, I acknowledge my understanding of the above options for use of the

photograph(s).

Child’s name(s):_____________________________________________

Print Parent/Guardian name:___________________________________

Signature:___________________________________________________

Reasons we would use your photo:

No Cavity Club

New patients

Contest Winners

RMPD fundraisers and events

The only place that we would use your picture is on our company website,

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