Maile S.C. Kim DDS, Bren M. Chun DDS

642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439

808-261-5354

FRENECTOMY PATIENT INFORMATION

Patient Name:
Preffered Name:
Phone:
Email:
Gender:
Birth Date:
Medical problems:

BIRTH HISTORY

Birth weight:
Present weight:
Medical problems:

MEDICAL HISTORY

Infants are usually given Vitamin K at birth to prevent bleeding in the first 8 weeks of life. Did you sign any waiver to refuse the administration of Vitamin K?
Has your infant had any surgery?
If yes, explain
Is your child taking any medications?
Do you or any immediate family members have any bleeding disorders?

NURSING HISTORY

Are you presently breastfeeding?
If no, how long since you stopped?
If yes, are you using a nipple shield?
If yes, are you also pumping?
Are you choosing not to breastfeed?
Are you supplementing with formula?

Infant’s symptoms

Mother’s symptoms

Pediatrician:
Ph:
Address :
City:
State:
Zip:
Email Address:
Has the pediatrician evaluated your infant’s lip and/or tongue tie(s)?
Lactation Consultant:
Ph:
Address :
City:
State:
Zip:
Email Address:
Who diagnosed your infant’s lip and/or tongue tie(s)?
How did you hear about our office?

Signature:

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Date:
Relationship:

REGISTRATION FORM

Patient Name:
Preffered Name:
Phone:
Email:
Patient’s SS#:
Birth Date:
FAMILY/RESPONSIBLE PARTY INFORMATION
Number of children in family:
Marital Status:
Parent's Name:
Birth date:
SS# :
Address:
City:
Zip:
Employment:
Phone:
Cell:
Military Rank:
Parent's Name:
Birth date:
SS# :
Address:
City:
Zip:
Employment:
Phone:
Cell:
Military Rank:
Please email appointment reminders to my email address:
Please text message appointment reminders to my cell phone:
Who may we thank for referring you to our office?
DENTAL INSURANCE INFORMATION

Primary Insurance:

Company:
Subscriber:
Subscriber ID/ SSN:
Group #:

Secondary Insurance (if applicable):

Company:
Subscriber:
Subscriber ID/ SSN:
Group #:
Person who is financially responsible for payment?
Initials
AUTHORIZATION AND FINANCIAL RESPONSIBILITY

1. I hereby authorize Howard Y.B. Kim DDS, Inc. to perform any and all dental treatment and to use such methods, drugs and agents as seen advisable. This authorization shall remain in effect until cancelled.

2. I hereby assume any and all financial responsibility for said child and hereby assign payment of all dental care insurance benefits to Howard Y.B. Kim DDS, Inc. and assume responsibility for fees not covered by my group insurance.

3. I hereby authorize Howard Y.B. Kim DDS, Inc. to provide any insurance company(s), claim administrators, and consulting health care professionals with information concerning health care, advice, treatment, or supplies provided. This information will be used exclusively for the purpose of evaluating and administering claims for benefits.

Signature

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Date:
Relationship

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