Pediatric New Patient Form

Richard Bowen, DDS	www.bowenlegacydental.com
Taryn Gehlert, DDS	Tel:614-459-2300

General, Cosmetic & Implant Dentistry	770 Jasonway Ave
	Columbus, OH 43214

PEDIATRIC PATIENT INFORMATION

Date:

Our passion is to provide you with a totally different experience. Giving you the results you are seeking with better communication and treatment options.We are creators of new lifestyles through smiles.

Patient Name:
I prefer to be called:
Birth Date:

Pediatrician Name:
Office Name (if different):

Pediatrician Phone:

Name of Guardian 1:
Relationship to patient:

Home Address:
City:
State:
Zip:

Home Phone:
Work Phone:
Cell:

Email:
Where do you prefer to receive calls?:

Birth date:
Soc.Sec#:

Name of Guardian 2:
Relationship to patient:

Home Address:(if different than above):
City:
State:
Zip:

Home Phone:
Work Phone:
Cell:

Email:
Where do you prefer to receive calls?:

Birth date:
Soc.Sec#:

Name and relation of additional people who have permission to bring the patient to appointments:

Name:
Relation:

Name:
Relation:

Name:
Relation:

How did you hear about our office?:

Internet search Online Reviews Print Media Personal Referral Social Media Patient Referral

Whom may we thank?:

GET TO KNOW ME

Favorite Hobby:
Favorite Sport:

Favorite Team:
Favorite Character:

Do you have siblings?:
Yes No

If yes, what are their names and ages:

Anything else you want to share?:

Richard Bowen, DDS	www.bowenlegacydental.com
Taryn Gehlert, DDS	Tel:614-459-2300

General, Cosmetic & Implant Dentistry	770 Jasonway Ave
	Columbus, OH 43214

FINANCIAL GUIDELINES

We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that the payment of your bill is considered part of your treatment.

We are a fee for service practice and collect in full at the time of service. If you have insurance, you will pay in full at the time of service and your insurance will reimburse you directly. We are committed to making decisions for each patient based on what is best for your overall health. Our office accepts cash, personal checks, MasterCard, Visa, Discover and CareCredit.

Do you have insurance?
As a courtesy to you, we are happy to file your dental claim on your behalf. Please note that Dr. Bowen is an in network provider with Delta Dental Premier and Dr. Gehlert is not an in network provider with any insurance companies. We will provide you with an insurance estimate. Understand this is not a guarantee of payment. Your insurance company and your plan benefit ultimately determine the amount paid.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company.

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning our financial policy.

I have read, understand and agree to the above conditions.

Patient Signature:
Date

INSURANCE INFORMATION

Do you have dental insurance?
Yes No
If yes dental insurance name?

Insurance company address:

Phone:
Group#
Policy#
Payor ID:

Name of policy holder:
Employer:

Policy holder DOB:
Policy holder SS#

Do you have Secondary Insurance?
Yes No

Richard Bowen, DDS	www.bowenlegacydental.com
Taryn Gehlert, DDS	Tel:614-459-2300

General, Cosmetic & Implant Dentistry	770 Jasonway Ave
	Columbus, OH 43214

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

I,have received a copy of this office's Notice of Privacy Practices.

Signature:
Date

*You may refuse to sign this acknowledgement*

Refusing:
Date

HIPAA Release of Information

I,authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:

Spouse

Child(ren)

Other

Information is not to be released to anyone

This release of information will remain in effect until terminated by me in writing.

Messages

Please call:
My home My work My cell

If unable to reach me:

You may leave a detailed message
Please leave me a message asking me to return your call

The best time to reach me is (day)
between (times)

Signature
Date

Witness
Date

Richard Bowen, DDS	www.bowenlegacydental.com
Taryn Gehlert, DDS	Tel:614-459-2300

General, Cosmetic & Implant Dentistry	770 Jasonway Ave
	Columbus, OH 43214

OXYGEN/OZONE THERAPY INFORMED CONSENT

I,, do voluntarily knowingly, and willingly give my consent to the administration of dental oxygen/ozone treatments. I seek this treatment at my own request. I understand that when having at treatment at Bowen Legacy Dental, dental oxygen/ozone will be used during most procedures.

I understand that dental oxygen/ozone therapy involves the injection of a mixture of oxygen and ozone in the form of a gas with or without local anesthetic. The injection can be given in the skin, mucous membranes, muscles, joints, jawbones, teeth, neck and/or other associated structures. Dental oxygen/ozone therapy is defined as the creation of a therapeutic oxygen rich environment, which induces a multi-factorial positive biochemical reaction. As a result, dental oxygen/ozone therapy kills bacteria, viruses, fungi and parasites. It is a circulatory stimulant, wound cleanser, accelerant for wound healing, hemostatic agent and an immune activating agent. There may be other effects that are not known at this time.

I understand that prior to any treatment involving injections with anesthetics I should tell the doctor or staff if I have ever experienced an allergic reaction to any anesthetic, particularly dental anesthetics.

Dental oxygen/ozone therapy carries with it some risk of side effects such as: pain and/or discomfort at the injection site, soreness and temporary bruising. There may be a red, inflamed, blister type area at the injection site. This area usually heals in 1-5 days. Although unusual, if an allergic reaction occurs, it is usually restricted to the injection site. The most common side effect is a warm or burning sensation at the site of the injection or flu-like symptoms for 2-3 days following treatment.

Patient/Legal Guardian:
Date