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

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

808-261-5354

REGISTRATION FORM

Patient Name:
Preffered Name:
Patient’s SS#:
Birth Date:
Phone:
Email:
FAMILY/RESPONSIBLE PARTY INFORMATION
Number of children in family:
Marital Status:
Parent's Name:
Last:
Birth date:
SS# :
Address:
City:
Zip:
Employment:
Phone:
Cell:
Military Rank:
Parent's Name:
Last:
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?
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 (s), 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
Dental Insurance:
Subscriber ID/ SSN:
Subscriber:
Person who is financially responsible for payment?
Initial

PATIENT INFORMATION

Patient Name:
Birth Date:
Gender:
Height:
Weight:
What is the purpose of your visit today?
Is your child in pain?

MEDICAL HISTORY

Name of Child’s Physician:
Phone:
Date of last visit
Is your child presently under the care of a physician for any medical disorder?
If Yes, describe
Has your child ever had surgery or been hospitalized for extensive care?
If yes, date & reason?
Does your child take any medication regularly or is he/she taking any medication now?
Medication/Dose:
Is your child allergic or sensitive to any foods or medications?
If yes, please indicate & reaction:
Has your child experienced any unfavorable reactions to previous dental or medical care?
If yes, when and what happened?
Is your child’s immunization up to date?

Please indicate if your child has had any of the following:

DENTAL HISTORY

Is this your child’s first visit to a dentist?
Previous dentist, date, & service
Birth History:
Does/Did your child do any of the following?
At what age did the child get his/her first tooth?
Start walking:
Start talking:
How does your child receive fluoride?
How often does your child brush?
How frequently does your child eat/drink sugary foods, candy, soda, juice, etc, between meals?
Have there been any injuries to your child’s teeth or jaw (falls, blows, chips, etc.?)
Incident (Please Explain):
Have any members of your family had any unusual dental problems
Incident (Please Explain):

To the best of my knowledge the above questions have been accurately answered.

Patient's Signature:

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Date:
Relationship:

Patient Management Techniques

Every effort will be made to obtain the cooperation of dental patients by the use of warmth, friendliness, humor, gentleness, kindness, and understanding. Should the dental patient exhibit signs of anxiety we will use pediatric dentistry behavior management techniques to obtain their confidence and cooperation. These management techniques are all routinely used to gain cooperation of your child, eliminate uncooperative behavior, or prevent the child from self-injury.

All techniques are accepted by the American Academy of Pediatric Dentistry:

  1. Tell-show-do: The dentist explains to the child what is to be done, then shows the child what is to be done by demonstration. Then the procedure is performed in the child’s mouth as described. Praise is used to reinforce cooperative behavior.
  2. Positive reinforcement: This technique rewards the child who displays any behavior which is desirable. Rewards included compliments, praise, a pat on the back, or a prize.
  3. Voice control: The attention of a disruptive child is gained by changing the tone or increasing the volume of the dentist’s voice. What is said is less important than the abrupt or sudden nature of command.
  4. Mouth props: A rubber or plastic device is placed in the child’s mouth to prevent closing when a child refuses or has difficulty maintaining an open mouth.
  5. Physical restraint by dentist/assistant/parent: The dentist restrains the child from movement by holding the child’s hands or upper body gently, stabilizing the child’s head between the dentist’s arm and body, or positioning the child firmly in the dental chair. This is for the safety of the child and to facilitate treatment.
  6. Nitrous Oxide (Laughing gas): This is administered to calm and soothe the patient prior to a stressful procedure. Nitrous oxide is a very safe medication that rarely causes nausea. The patient does not sleep, unless already tired before the appointment.
  7. Protective Stabilization (papoose board): This is a restraining device to limit the patient’s disruptive movements to prevent injury. It is used as a last resort when treatment can be accomplished no other way.

The listed pediatric dentistry behavior management techniques have been explained to me. I understand their use, and the risks/benefits/alterations available. I have had all my questions answered and I realize I can always seek further information or revoke permission for any of these techniques.

I acknowledge that I have read and understand this consent form, that I have been given an opportunity to ask any questions I may have, and that all questions about the behavior management techniques described have been answered in a satisfactory manner. I give my consent to needed dental services and use of proper and acceptable methods to complete the treatment for my child

Signature:

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Relationship:

CONSENT/AUTHORIZATION FOR DENTAL TREATMENT OF A MINOR

Patient Name:
Date of Birth:

It is the policy of Kim Pediatric Dentistry (Howard Y.B. Kim DDS, Inc.) that all minors be accompanied by a parent or legal guardian for their dental visits. We do understand that under certain circumstances, you would prefer another caregiver to accompany them.

All minors seeking dental treatment MUST be accompanied by a parent/legal guardian during the initial office visit. After the initial appointment, a minor may be seen for treatment only with written authorization from the parent/guardian under the conditions specified in this consent. If you need to send your child to their appointment with an adult other than yourself/legal guardian, please complete this section:

I, (parent/legal guardian) , cannot accompany my child,(child’s name) , to their appointment(s) with Kim Pediatric Dentistry.

Therefore, I give permission to:

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:

Consent Conditions (check all that applies below):

(Please check one of the following below)

* I understand I am responsible for all charges or fees incurred and co-payments must be made at the time of service as our financial policy states. We will gladly process payments over the phone if a credit card is used.

Parent's/Guardian Signature:

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Date:

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