O'Rourke Family & Cosmetic Dentistry

Child Dental History

Patient Health Record:
  • Child's Name:
  • Age:
  • Date of Birth:
  • SS#:
  • Date:
  • Guardian 1:
  • Name :
  • Relationship to patient:
  • Home Address:
  • City:
  • State:
  • Zip:
  • Home Phone:
  • Work Phone:
  • Cell Phone:
  • Email:
  • Where do you prefer to receive calls?:
  • Home Work Cell
  • Birth date:
  • Soc.Sec#:
  • Guardian 2:
  • Name :
  • Relationship to patient:
  • Home Address:(if different than above):
  • City:
  • State:
  • Zip:
  • Home Phone:
  • Work Phone:
  • Cell Phone:
  • Email:
  • Where do you prefer to receive calls?:
  • Home Work Cell
  • Birth date:
  • Soc.Sec#:
  • Insurance Co:
  • Policy #:
  • Gp#:
  • Insured's ID #:
  • Insured Date of Birth
  • Address for Insurance Submission:
  • Spouse Employer:
  • Spouse Ins. Co:
  • Who will bring the child to the office and their cell number:
  • Will the child be driving themselves?
  • Yes No
  • Who will be the responsible financial party?
  • Who is the Insurance Subscriber?
  • How did you find us?
  • Billboard Church Bulletin Pinecrest Academy Website Direct Mail
  • Whom may we thank for referring you to us?
  • Patient
  • Other

Medical History
  • Child's Name:
  • Date of Last Physical Exam:
  • Name/Phone Number of Physician:
  • Have you been hospitalized or under a physician's care in past 2 years?
  • YES NO
  • For:
  • Any major surgeries?
  • Yes No
  • If yes, describe:
  • Knee or Hip Replacement?
  • Yes No
  • Date:
  • Do you take antibiotics prior to dental work?
  • Yes No
  • Are you pregnant or nursing?
  • Yes No
  • Do you take birth control pills?
  • Yes No
  • Do you take osteoporosis meds, Fosamax, Boniva or other bisphosphonates?
  • Yes No
  • Allergic to:
  • Aspirin Codeine Latex Local Anesthetics NSAIDS Penicillin Foods
  • Please list ALL medications and supplements:
    • Have you had, or do you now have:
    • (*if yes, list date and diagnosis)
  • Yes No
    High Blood Pressure
    Atrial Fibrillation
    AIDS/HIV Positive
    Angina/Chest Pain
    Artificial Heart Valves
    Artificial Joints
    Compromised Immunity
    Congenital Heart Defect
    Drug Dependency
  • Yes No
    Gastric Reflux
    Heart Attack
    Herpes/Fever Blister
    Kidney Disease
    Liver Disease
    Organ Transplant
    Prolonged Bleeding
    Prolonged Cough
    Psychiatric Care
    Recreational Drug Use
  • Yes No
    Radiation Therapy
    Respiratory problems
    Rheumatic Fever
    Severe Gag Reflex
    Sickle Cell Anemia
    Sleep Apnea
    Thyroid Disease
    Ulcers Stomach

    Anything Not Listed:

  • I understand that withholding any information could seriously jeopardize my safety and I have answered truthfully to the best of my knowledge
  • I consent to a dental exam including x-rays,photographs, study models or other diagnostic aids deemed appropriate by the doctor to make a complete diagnosis of my current dental condition
  • Signature
  • Date:

Your Young Child's Dental Health - What You Should Know
  • Child's Name:

The American Dental Association recommends that children be seen by a dentist as soon as their first tooth erupts, but at least no later than the first birthday. A dental visit at an early age is a "well baby checkup" for the teeth.

Parents should be brushing baby teeth as soon as they erupt without fluoridated toothpaste. Supervise tooth brushing to make sure children over 2 years of age use only a pea sized amount of fluoride toothpaste and avoid swallowing it. Children should be taught to spit out remaining toothpaste and rinse with water after brushing. Most children will be able to brush on their own by the age of 6 or 7 years.

Parents should be using floss on their children's teeth as soon as any two teeth touch. Cleaning between the teeth is important because it removes plaque where a toothbrush cannot reach.
Brush your child's teeth twice a day. The baby teeth are extremely important in keeping a mouth healthy. If a cavity develops in the baby teeth, it grows very rapidly and can lead to dental pain and infection of the underlying permanent teeth. Any drink containing sugar and/or citric acid (all sodas, sports drinks, juices, etc.) make the teeth more susceptible to cavities by lowering the pH of the mouth so bacteria can thrive. Please limit these so your child can have a healthy mouth.

Once the permanent molars erupt (usually around age 6), we recommend sealing the tops of the teeth to prevent decay with dental sealants . If your child is cavity prone, we can also seal the tops of the primary teeth as well for prevention.

Help your children maintain a lifelong healthy smile by providing them with a well- balanced diet, limiting starchy and sugary snacks , ensuring that they brush twice per day and floss once per day, and scheduling regular dental checkups for them.

Please call our office should you have any questions about your child's dental health.

O'Rourke Family & Cosmetic Dentistry

757 Peachtree Pkwy #1 | CUMMING GA, 30041 | (770) 888-6285


Thank you for choosing O'Rourke Family & Cosmetic Dentistry. We strongly feel our patients deserve the best possible care and we would like to share some facts about dental insurance with you.

Fact 1: Dental insurance is NOT meant to be a PAY-ALL, it's only meant to aid

Fact 2: Many plans tell their insured they will be covered "up to 80%-100%." Despite what you are told, we have found that most plans cover 40% to 70% of an average fee. The amount that your plan pays is determined by THEIR fee schedule and those benefits are largely based on how much your employer paid for the plan. Remember, you get back only what the employer puts in, less the profits of the insurance company. Most insurance plans have a maximum benefit and a deductible each year that has not changed since the 1970's.

Fact 3: It has been the experience of many dentists that some insurances tell their customers the "fees are above the usual and customary fee" when a much more accurate statement would be, "Any difference in the fee charged, and the benefits paid, is due to limitations in the plan contract."

Fact 4: Some dental services are not covered by insurance carriers. Please do not hesitate to ask us any questions about our policies. We want you to be comfortable in dealing with these matters, and we urge you to consult with us if you have any questions regarding our services and/or fees. We will gladly file with your insurance company and will make every effort to maximize your insurance benefits.

However, please remember that ultimately, you are financially responsible for your account with our office, not your insurance company.

I authorize payment of dental treatment directly to O'Rourke Family and Cosmetic Dentistry for all dental services:

I authorize release of any dental information necessary to process insurance claims:

  • Signature
  • Date

Financial Responsibility
  • Child's Name
  • Thank you for choosing O'Rourke Family & Cosmetic Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of this mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

  • Payment Options
  • Cash, Check, Visa, Mastercard, American Express and Discover
  • To qualify for our 5% discount, you must PrePay for your treatment in FULL with Cash or Check prior to your scheduled treatment appointment.
  • Monthly Financing Options Available:
  • * NO INTEREST Payment Plans from CareCredit
    Allow you to pay over time, 6-12 months, with NO interest (subject to credit approval). No annual fees or pre-payment penalties
  • For Patients with Dental Insurance:
  • For patients with dental insurance: we are happy to work with your primary dental insurance carrier to maximize your benefit and directly bill them for reimbursement for your treatment. You are responsible for your estimated payment at time of service.
    We are Non Participating providers for all insurance. Some insurances companies pay the patient directly, not us. This is a function of each specific plan your employer has chosen for you. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract.
    Please remember you are fully responsible for all charges by this office regardless of your insurance coverage. We will file ONE appeal on your behalf. If your insurance carrier has not paid the claim within 60 days, your are responsible for the entire balance and finance charges of 18% APR will incur. A $25 late fee may be assessed on your account if amount due is not paid by due date.
    O'Rourke Family & Cosmetic Dentistry charges $35 for returned checks.
  • $50 will be charged to your account for missed dental appointments without 24 hour notice.
  • If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want and need.
  • Patient, Parent or Guardian Signature
  • Date

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