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  • About Us
    • Who Are We
    • Our Core Purpose & Values
    • Our Story
    • Represented Brands
  • Careers
    • Career Opportunities
    • Culture
  • Want To Connect?
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Kids Dental Brand
  • About Us
    • Who Are We
    • Our Core Purpose & Values
    • Our Story
    • Represented Brands
  • Careers
    • Career Opportunities
    • Culture
  • Want To Connect?

Yuma Mobile Patient Enrollment Form

Step 1 of 9

11%
  • nombre del estudiante
  • Fecha de nacimiento
    Date Format: MM slash DD slash YYYY
  • género
  • madre/padre
  • número de teléfono
  • correo electrónico
  • habla a
  • colegio
  • grado
  • seguro
  • Seguro privado
  • Teléfono seguro
  • Nombre del suscriptor
  • Fecha de nacimiento del suscriptor
    Date Format: MM slash DD slash YYYY
  • Número de póliza
  • Numero de grupo
  • Seguro militar
  • Teléfono de seguro
  • Nombre del suscriptor
  • Fecha de nacimiento del suscriptor
    Date Format: MM slash DD slash YYYY
  • Rango militar
  • Número de póliza
  • Numero de grupo
  • Número de identificación de AHCCCS
  • HEALTH HISTORY (HISTORIA DE SALUD)

    Please indicate if your child has had any of the following health problems (check all that apply)
  • HISTORIA DE SALUD
  • ¿Su hijo tiene necesidades especiales?
  • ¿Toma su hijo algún medicamento recetado o de venta libre?
  • Por favor enumere los medicamentos
  • ¿Su hija tiene alguna alergia conocida?
  • ¿Alergia al látex?
  • Otra alergia?
  • ¿Está embarazada su hija?
  • ¿Está su hija bajo control de la natalidad?
  • ¿Su hija consume bebidas alcohólicas?
  • ¿Fuma, mastica, usa tabaco u otras formas de tabaco (incluido el vaporizador)?
  • ¿Hay algo más que deberíamos saber que no se cubrió en las preguntas anteriores?
  • Por favor liste
  • DENTAL TREATMENT CONSENT

    I am the parent of the child named above. I give consent for my child to receive the dental screening/assessment and oral health services by an Affiliated Practice Dental Hygienist. To the best of my knowledge, the medical history questions have been answered accurately. I allow my child to receive x-­‐rays, cleaning, sealants and/or fluoride treatment that may be recommended. The services provided are subject to change depending on numerous factors, including the patient’s behavior, the amount of future work needed and time. • Preventative/Diagnostic procedures: x-­‐rays, prophylaxis (cleaning), fluoride treatment and sealants when necessary (these services will be billed to insurance) • Visual Exam I understand that the Affiliated Practice Dental Hygienist providing the care is an Arizona licensed dental hygienist and that this care does not take place of a complete examination or dental care. I understand that the hygienist will refer my child to a dentist for treatment outside the hygienist’s scope of practice, and that if my child has not received treatment, the dental hygienist may not provide further treatment.
  • CONSENT TO PRIVACY PRACTICE

    I understand that, under the Healthy Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. PLEASE READ THE ATTACHED NOTICE OF PRIVACY PRACTICES EXPLANATION TO ENSURE YOU UNDERSTAND YOUR RIGHTS TO PRIVACY AND KEEP IT FOR YOUR RECORDS. By placing my electronic signature below, I agree that I have been informed of my NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such NOTICE OF PRIVACY PRACTICES prior to e-signing this consent. I understand my rights to the privacy of my personal information.
  • ELECTRONIC COMMUNICATIONS CONSENT

    This office has offered to communicate using the following means of electronic communication: Email, Social Media, Videoconferencing Appendix A https://bit.ly/36hhBtw PATIENT ACKNOWLEDGMENT and AGREEMENT https://bit.ly/2NNn2tz
  • RECONOCIMIENTO Y ACUERDO DEL PACIENTE
  • Consentimiento - Acepto la política de privacidad.
Contact Us
  • 5717 E. Thomas Road, Suite #100, Scottsdale, AZ 85251
  • +1 480.607.9999
  • +1 480.607.9989
  • hello@just4grins.com
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