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?:
    • PEDIATRIC HEALTH HISTORY
    • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that
    • you may have or medications that you may be taking could have an important interrelationship with the dentistry you will receive.
    • Thank you for answering the following questions.
    • Has the child had any history of, or conditions related to any of the following.
    • Please mark any that apply:
    • Anemia
      AIDS/HIV
      Arthritis
      Asthma
      Bladder
      Bleeding disorders
      Bones/Joints
      Bruise Easily
      Cancer
      Cerebral Palsy
      Chemo
      Chicken Pox
      Chronic Sinusitis
    • Diabetes Type:
      Cold Sore
      Ear Aches
      Epilepsy
      Fainting
      Growth Problems
      Hearing
      Heart
      Immunizations
      Kidney
      Latex Allergy
      Liver
      Measles
    • Hepatitis Type:
      Mononucleosis
      Mumps
      Pregnancy (teens)
      Rheumatic Fever
      Seizures
      Sickle Cell
      Stomach
      Thyroid
      Tobacco/Drug Use
      Tonsillitis
      Tuberculosis
      Venereal Disease
    • Other Medical Conditions:
    • Is the child taking any prescription and/or over the counter medications at this time?:
    • Yes No
    • If yes, please list:
    • Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs?
    • Yes No
    • If yes, please list and explain:
    • Has the child ever had a serious illness?:
    • Yes No
    • If yes, when:
    • Please describe:
    • Has the child ever been hospitalized?:
    • Yes No
    • Has the child ever received a general anesthetic?:
    • Yes No
    • If yes, for what:
    • Does the child experience excessive bleeding when cut?:
    • Yes No
    • Please check if either parent has any of the following:
    • Missing Teeth Sleep Apnea
    • PEDIATRIC DENTAL HISTORY
    • Is this the child's first visit to a dentist?:
    • Yes No
    • If no, when was patient first seen:
    • Last Dental Visit:
    • Has the child had any problem with dental treatment in the past?:
    • Yes No
    • If yes, explain:
    • Has the child ever had dental radiographs (x-rays) exposed?:
    • Yes No
    • Has the child ever suffered any injuries to the mouth, head or teeth?:
    • Yes No
    • If yes, please explain:
    • Has the child had any problems with the eruption or shedding of teeth?:
    • Yes No
    • Has the child had any orthodontic treatment?:
    • Yes No
    • Does your child use fluoride toothpaste?:
    • Yes No
    • How many times are the child's teeth brushed per day?:
    • Does your child use fluoride toothpaste?:
    • Does the child suck his/her thumb, finger or pacifier?:
    • Yes No
    • At what age did the child stop bottle feeding? Age:
    • Breast feeding? Age:
    • PEDIATRIC SLEEP AND AIRWAY
    • Does the child have any speech difficulties?:
    • Yes No
    • If yes, please explain:
    • Does the child snore at night?:
    • Yes No
    • Does the child grind teeth at night?:
    • Yes No
    • Does the child breath with his/her mouth open?:
    • Yes No
    • Does the child have allergy symptoms?:
    • Yes No
    • Does the child have restless sleep?:
    • Yes No
    • Does the child have frequent headaches?:
    • Yes No
    • PEDIATRIC GROWTH AND NUTRITION
    • Does your child follow a special diet?:
    • Yes No
    • If yes, explain:
    • What type of water does your child drink?:
    • City Water Well Water Bottled Water Filtered Water Alkaline Water
    • What beverages do your child consume?:
    • Does your child have any food allergies or sensitivities?:
    • Yes No
    • If yes, explain:
    • How would you describe your child's eating habits:
    • Please list 3 of your child's favorite foods:
    • Does your child participate in active recreational activities?
    • Yes No
    • If yes, please list a few:
    • Does your child take any supplements?
    • Yes No
    • If yes, please list:
    • Describe your child's emotional well-being:
    • Happy Sad Easy Going Withdrawn Relaxed Agitated Other
    • Was the child born premature?
    • Yes No
    • If yes, what was the gestational term?:
    • Any complications during pregnancy?
    • Yes No
    • If yes, please explain:
    • PEDIATRIC COMPREHENSIVE/HOLISTIC THERAPIES
    • Does your child use any essential oils?
    • Yes No
    • If yes, explain:
    • Does your child see a chiropractor?
    • Yes No
CONSENT TO DENTAL PHOTOGRAPHY
    • I, authorize Bowen Legacy Dental, to take photographs, and/or videos of my face, jaws and teeth, before during and after treatment.

    • I consent to allow the photographs to be used for the follow:
    • 1) Dental Records
    • 2) Dental Research
    • 3) Dental Education including lectures, seminars, demonstrations and professional publications such as journals or books
    • 4) Marketing material, including websites and printed materials, patient education and social media posts
    • I further understand that if the photographs and/or videos are used, my full name and/or other identifying information will be kept confidential.
    • I do not expect compensation, financial or otherwise, for the use of these photographs.
    • Patient Signature:
    • Date
    •  
    • -OR-
    •  
    • I do not want my full-face shot used for any of the above purposes
    • Patient Signature:
    • Date
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 payment of your bill is considered part of your treatment.

    • Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa and Discover. Outside financing is available upon request and approval.
    • Please check if you would like more information about financing options.
    • Please note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges incurred.
    • Do you have insurance?
    • 1) As a courtesy to you we will help you process all insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefit ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.

    • 2) 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. Your insurance policy is a contract between you, your employer and your insurance company. Our office is not a party to that contract.

    • 3) Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
    • 4) If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
    • We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.
    • I have read, understand and agree to the above terms and 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 dental oxygen/ozone therapy involves the injection of mixture of oxygen and ozone in the form of a gas with or without local anesthetic, into the skin, mucous membranes, muscles, joints, jawbones, and teeth of the head, neck and associated structures. Dental oxygen/ozone therapy is defined as the creation of a therapeutic oxygen rich environment, which induces a multi-factorial positive biochemical and following dental relevant and useful properties: it kills bacteria, viruses, fungi and parasites. It is circulatory stimulant, a wound-cleanser, and accelerant for wound healing, a hemostatic agent, and an immune activating agent. There may be other effects that at this time are unknown.
    • I understand that I should tell the doctor or staff if. I have ever had an allergic reaction to any anesthetic, particularly dental anesthetics prior to any treatment involving injections with anesthetics.
    • There are potential side effects with all types of dental treatments. 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 a 1-5-day time period. All types of medications have some risk of allergic reactions. An allergic reaction to the mixture of oxygen/ozone would be unusual and usually restricted to the injection site. The most common patient comment is that there is a warm to burning sensation at the site of the injection. Some patients any experience flu-like symptoms for 2 to 3 days following treatment.
    • Patient/Legal Guardian:
    • Date
    • Witness:
    • Date

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