Danville Pediatric Dentistry - Monica Mosley, DDS

4545 Riverside Drive • Suite C • Danville, VA 24541 • Telephone: (434) 791-2142 • FAX: (434) 791-2185

Demographic Information

Patient *

Today's Date *

Nickname

Guardian's Email *

Birthday *

Age *

Sex *

Ethnicity *

Home Phone *

Cell Phone *

Secondary Cell Phone

Home Address *

Address Line 1

City

State

Zip Code

Names and ages of siblings

Patient School *

Patient Grade *

Parent/Legal Guardian *

Relation to patient *

Employer *

Phone

Who has legal custody of patient? *

Dental Insurance *

Yes
No

Person responsible for payment of account *

SS#

DOB *

Name of child’s physician/group *

City/St *

Phone *

Whom may we thank for referring you to us?

What is the reason for your child’s dental visit? *

Health History

Is your child in good health? *

Yes
No

Date of last physical exam *

Has your child ever had a health problem? *

Yes
No

Is your child current on their vaccinations? *

Yes
No

If no, please explain

Has your child ever been hospitalized? *

Yes
No

Please give reason and dates

Is your child allergic to anything? *

Yes
No

Is your child currently taking any medications? *

Yes
No

Please give medication, dose and reason

Were there any problems at birth? *

Yes
No

Please elaborate on any items checked:

Do you consider your child to be: *

advanced in the learning process
progressing normally
slow in the learning process

Was your child:

breast fed
bottle fed

At what age stopped:

Dental History

Has your child ever been to the dentist? *

yes
no

Date of last xrays (if taken)

Name of dentist and date

Has your child experienced any unfavorable reaction from previous dental care? *

yes
no

Explain

Does your child suck a finger, thumb or pacifier? *

yes
no

Does your child have pain with chewing, yawning, or wide opening? *

yes
no

Does your child’s jaw make noise and is pain associated with the sounds? *

yes
no

Please estimate your child’s daily exposure to the following items:

Soda *

Cereal bars/granola bars *

Juice *

Gummies/gummy vitamins *

Sports drinks *

Fruit snacks/fruit roll-ups *

Cookies/crackers *

Dried fruit *

Choco/Strawberry Milk *

Potato Chips *

Fluoride History

Is your home water supply fluoridated? *

yes
no

Does your child use a fluoride toothpaste? *

yes
no

Do you give your child any other form of fluoride? *

yes
no

What?

Consent for Dental Treatment

I request and authorize Dr. Mosley to examine, clean, and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Mosley to diagnose and/or treat my child’s dental problem. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Mosley will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. I will be responsible for any charges incurred on this child for dental treatment.

Signature *

Date *

Financial Agreement

Thank you for choosing Danville Pediatric Dentistry for your child’s dental care.
Please read our financial agreement. Sign and date prior to any treatment.

For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
I will pay a $25 fee for appointments broken without 24 hour notice.

Treatment plans sometimes change, and I will be responsible for the work completed on the date of service.

In an effort to make our patients' dental care affordable, payment is required at the time of treatment. If you do not have dental insurance, full payment is due at the time of service. If you have dental insurance, we require an estimated co-payment on the date services are rendered. If your account has an overdue balance, future treatment may be delayed until your balance has been paid in full. For your convenience, we accept cash, check, CareCredit or credit. We do not offer payment plans.

DENTAL INSURANCE

I understand that fees for services not covered by my insurance are my financial responsibility. Any insurance quote received from Danville Pediatric Dentistry is only an estimate of your dental benefits and not a guarantee of payment. If your insurance is ineligible on the date of service, you are responsible for all payments. As the insured, it is your responsibility for the understanding of your policy.

PLEASE KEEP IN MIND OUR FINANCIAL POLICY APPLIES TO WHOEVER BRINGS THE CHILD IN FOR TREATMENT. THAT PERSON IS FINANCIALLY RESPONSIBLE FOR ANY CHARGES INCURRED ON THE DAY OF THE APPOINTMENT. WE DO NOT SEND STATEMENTS TO OTHERS OR OTHER PARENTS.

Please note that Danville Pediatric Dentistry is in network with Delta Dental and VA and NC Medicaid. We will file all other insurances as a courtesy to our patients but the balance due will be the responsibility of the legal guardian.

I have read, understand, and agree to the Danville Pediatric Dentistry financial agreement.

Patient Name *

Signature of Parent/Legal Guardian *

Date *

Print Parent/Legal Guardian Name *

New Patient Paperwork