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Child/Adolescent Registration Form A

Child/Adolescent Registration Part A

Step 1 of 9

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CHILD/ADOLESCENT ACQUAINTANCE FORM

Todays Date(Required)

MM slash DD slash YYYY

Patient Name(Required)

First Last

Patient Sex(Required)

Male

Female

Birth Date(Required)

Parent/Gaurdian

Parent / Guardian Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone (Home or Cell)(Required)

Secondary Phone (Home or Cell)

Work Phone

Email(Required)

Drivers License

State

Employer

Occupation

Primary Care Physician

Phone

Address

Street Address

Pharmacy Name

Pharmacy Phone

Main Cross Streets

Whom may we thank for this referral?

Emergency Contact(Required)

Emergency Phone(Required)

Relationship to Patient(Required)

GUARANTOR INFORMATION – IF DIFFERENT FROM ABOVE

Guarantor Name

First Last

Relationship to Patient

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Sex

Male

Female

Birth Date

Employer

Occupation

MEDICAL INSURANCE INFORMATION

Medical Information

None

Patient Name

First Last

Birth Date

Insurance Co. Name

Employer of Policy Holder

Policy Holder Name

Relationship to Patient

Insurance Claims Address

Insurance Claims Phone

Policy Holder Birthdate

Month

Day

Year

Insurance ID

Group

Effective Date

MM slash DD slash YYYY

DENTAL INSURANCE INFORMATION

Dental Information

None

Patient Name

First Last

Birth Date

Insurance Co. Name

Employer of Policy Holder

Policy Holder Name

Relationship to Patient

Insurance Claims Address

Insurance Claims Phone

Policy Holder Birthdate

Month

Day

Year

Insurance ID

Group

Effective Date

MM slash DD slash YYYY

Thank You

Thank you for choosing our practice for your healthcare needs. We greatly appreciate your trust and confidence in our expertise and consider it an honor and privilege to help you and your family.

We chose to build a patient-centered model for our practice that does not allow insurance companies to dictate the care we provide. This means that we are not contracted with insurance carriers. Because of this, we collect payment directly
from the patient during the time of your visit.

Our office does, however, provide concierge billing services and will work directly with your insurance company to file for any out of network benefits your insurance company offers, so that your insurance company may reimburse you directly according to the terms of your policy.  Our consultation, procedure, and follow-up service fees are in accordance with the following schedule. Because most
insurance companies provide reimbursement based on a fee-for-service payment plan, you may notice some variance between the amount billed to your insurance company and the fees we collect from you as a patient. 

ASSIGNMENT OF BENEFITS:
I assign all medical and/or surgical benefits to which I am entitled including major medical, Medicare, Private Insurance and any other health plan to The Stewart Center for Optimal Health. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges and I authorize said assignee to
release all information necessary to secure payment.

***PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED***

Signature(Required)

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.

Acknowledgement

The undersigned acknowledges a receipt of a copy of the current effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated documents shall be as effective as the original.

MY SIGNATURE WILL ALSO
SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

Patient Name(Required)

Birth Date(Required)

Legal Representative / Guardian(Required)

Relationship of Legal Representative / Guardian(Required)

I AUTHORIZE CONTACT FROM THIS OFFICE CONFIRM MY APPOINTMENTS, TREATMENT, & BILLING INFORMATION VIA:(Required)

Cell Phone Confirmation

Text Message

Email Confirmation

Work Phone Confirmation

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:(Required)

Cell Phone Confirmation

Text Message

Email Confirmation

Work Phone Confirmation

I APPROVE BEING CONTACTED ABOUT SPECIAL SRERVICES, EVENTS, FUNDRAISING EFFORTS, NEWS/EVENTS or NEW HEALTH INFO ON BEHALF OF THIS HEALTHCARE FACILITY VIA:(Required)

Cell Phone Confirmation

Text Message

Email Confirmation

Work Phone Confirmation

Signature(Required)

THE STEWART CENTER FOR OPTIMAL HEALTH HAL STEWART, DDS, PLLC - PATIENT AND STORY SUBJECT RELEASE FORM

I do hereby give Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health (the “Publisher”) and Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health and its affiliates (“Affiliates” includes any entity which, now or in the future, controls, is controlled by, or is under common control with Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health) the irrevocable right to use my
name (or any fictional name), picture, portrait, story, likeness or photograph in all forms and in all media and in all manners, without any restrictions as to changes or alterations (including but not limited to composite or distorted representations or derivative works
made in any medium) for advertising, trade, promotion, exhibition, or any other lawful purposes, and I waive any right to inspect or approve the photograph(s) or finished version(s) incorporating the photograph(s), including written copy that may be created and appear in connection therewith. I hereby forever release and agree to hold harmless Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health (the “Publisher)
and Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether international or otherwise, that may occur or be produced in the taking of other photographs, creation of the story, or in any processions tending toward the completion of the finished product, unless it can be shown
that they and the publication thereof were maliciously caused, produced, and published solely for the purpose of subjecting me to conspicuous ridicule, scandal, reproach scorn, and indignity.
I agree that the Publisher and its contractor Hal Stewart, DDS, PLLC/The Stewart Center for Optimal Health, owns the license in these photographs and I hereby waive any claim I may have based on any usage of the photographs, written story, or works derived there
from, including but not limited to claims for either invasion of privacy or libel. I am of full age* and competent to sign this release. I agree that this release shall by binding on me, my legal representatives, heris, and assigns. I have read this release and am fully
familiar with its contents.

Consent(Required)

I Accept

I Decline

Patient Name(Required)

First Last

Birth Date(Required)

*Consent Required for Non-Adults

*Consent Required for Non-Adults

I am the parent or guardian of the minor named above and have legal authority to execute the above release. I approve the foregoing and waive any rights in the premises

Parent/Guardian Name(Required)

First Last

Signature(Required)

Medical Background Information

Chief Complaints and Goals(Required)

History of Present Illness/Condition(Required)

Current Medications and purpose (including prescription and over-the-counter)(Required)

Please write the prescriptions as a list

Have you ever been required to pre-medicate?(Required)

Yes

If yes – please list

Are you allergic to any medication?(Required)

Yes

If yes – please list

Present allergies?(Required)

Yes

Allergies

Seasonal

Dust

Pets/Dander

Food/Other

Latex

Food Allergies

Have you been formally tested for allergies?(Required)

Yes

What else do you do to relieve symptoms?

Saline Spray

Inhaled Steroid

Afrin

Acupuncture

Oral Medication/Decongestant

Neti Pot/Navage

None

Other

Current use of a CPAP/BiPAP?(Required)

Yes

Past use of a CPAP/BiPAP?(Required)

Yes

PAST SURGICAL HISTORY(Required)

FAMILY MEDICAL HISTORY

Mother: Alive(Required)

Yes

Age

Does your mother have a history of any of the following medical illnesses? (Select all that apply):(Required)

High Blood Pressure/Hypertension

Heart Disease

Congestive Heart Failure

Depression

Diabetes

Overweight/Obesity

Snoring

Sleep Apnea

Anxiety

Chronic Insomnia

Restless Leg Syndrome

Multiple Sclerosis

Sleep Walking

Neurologic Issues

Stroke

Unknown

None

Father: Alive(Required)

Yes

Age

Does your father have a history of any of the following medical illnesses? (Select all that apply):(Required)

High Blood Pressure/Hypertension

Heart Disease

Congestive Heart Failure

Depression

Diabetes

Overweight/Obesity

Snoring

Sleep Apnea

Anxiety

Chronic Insomnia

Restless Leg Syndrome

Multiple Sclerosis

Sleep Walking

Neurologic Issues

Stroke

Unknown

None

ADDITIONAL INFORMATION:

SOCIAL HISTORY

School / Grade Level(Required)

Extracurriculars / Sports(Required)

Caffeine:

Number of cups of coffee per day(Required)

Number of energy drinks per day(Required)

Number of cans or glasses of soda per day(Required)

Number of cups of tea per day(Required)

Number servings of chocolate per week(Required)

Siblings(Required)

Yes

How Many?

Pets(Required)

Yes

How many and type of pet?

Do you have any siblings or pets that sleep in your bedroom?(Required)

Siblings

Pets

None

EARLY CHILDHOOD

Early Childhood - Check All That Apply(Required)

Bottle Fed

Difficulty Latching or Feeding

Tongue-Tied or Lip-Tied as infant

Sippy/Straw Cups

Breast Fed

Premature Birth

Long or difficult labor

C-Section

Breach

Pacifier Use

Not Sure

Other

None

Notes/Other

Past oral habits - Check All That Apply(Required)

Thumb sucking

Finger sucking

Nail biting

Prolonged pacifier use

Sucking on clothing/hair/blanket/etc

Chew on Ice/Other Objects

Other

None

Notes/Other

Current oral habits? Check All That Apply(Required)

Thumb sucking

Finger sucking

Nail biting

Prolonged pacifier use

Sucking on clothing/hair/blanket/etc

Chew on Ice/Other Objects

Other

None

Notes/Other

SPEECH THERAPY

Have you ever been evaluated by a speech language pathologist?(Required)

Yes

Speech Therapist

If treated, what was the focus of speech therapy?

Have you ever been evaluated by an orofacial myofunctional therapist?(Required)

Yes

Orofacial Myofunctional Therapist

If treated, what was the focus of therapy?

Do you have current speech/myofunctional concerns?(Required)

Yes

If so, what are they? Check

“S” sound or lisp

Voice projection

Gag Reflex

Tongue Thrust

“R” or “L” problems

Mouth Breathing

Drooling

Tongue Tie

General lack of clarity or mumbling

Swallowing Issues

Noisy Eater

Choking while eating

Notes/Other

REVIEW OF SYSTEMS

Constitutional - Check All That Apply(Required)

Loss of Appetite

Sweats

Fever

Fatigue

Weight Gain

Weight Loss

Weight Management Medication

None

Respiratory - Check All That Apply(Required)

Cough

Asthma

Wheezing

Shortness of Breath

Poor Exercise Tolerance

None

Gastrointestinal - Check All That Apply(Required)

Gerd

Acid Reflex

Heartburn/Indigestion

Black or Bloody Stools

Diarrhea

Irritable Bowel Syndrome

Nausea/Vomiting

Jaundice

Abdominal Bloating or Cramping

Belching

Flatulence

Leaky Gut

Laryngopharyngeal Reflux (LPR)

Small Intestinal Bacterial Overgrowth

None

Frequency of Gastrointestinal Symptoms

Daily, Weekly, 3x/mo., etc

Genitourinary - Check All That Apply(Required)

STI/STD

Bed Wetting

Frequent Urination

Frequent Urination at Night

Difficulty Urinating

Blood in Urine

Erectile Dysfunction

None

Reproductive - Check All That Apply(Required)

Abnormal Menses

Fibroids/Ovarian Cysts

Endometriosis

PCOS

None

Allergy/Immunology - Check All That Apply(Required)

Sneezing

Runny Nose

Itchy Eyes or Nose

Hives

Nasal Allergies

None

Musculoskeletal - Check All That Apply(Required)

Osteoporosis/Osteopenia

Taking Biphosphat

Muscle Pain

Red or Swollen Joints

Arthritis/Rheumatoid Arthritis

TMJ PAin/Jaw Discomfort

Lupus

Fibromyalgia

Stiff/Sore Joints

None

Eyes - Check All That Apply(Required)

Contact Lenses/Glasses

Glaucoma

Blurry Vision

Vision Loss

None

Ears/Nose/Throat/Mouth - Check All That Apply(Required)

Hearing Loss

Sore Throat

Sinus Congestion

Hoarseness

History of Ear Problems/Infections

Current Ear Problems/Infections

Vertigo

Septoplasty or Rhinoplasty

Turbinate Reduction

Tinnitus

Nasal Polyps

Chin Implants

Nostril Collapse (Fast Inhale)

Empty Nose Syndrome

Frequent Sinuses/Pressure

Tonsils Removed

Adenoids Removed

Tubes Replaced

None

If you checked yes to tonsils or adenoids removed, please specify what age you had this done

Cardiovascular(Required)

High Blood Pressure

Low Blood Pressure

Stroke

Heart Attack

Palpitations/Arrhythmia

Chest Pain

Daytime Shortness of Breath

Nighttime Shortness of Breath

Ankle Swelling

None

Skin - Check All That Apply(Required)

Unusual Moles

Rash

Dryness

Cold Sores

None

REVIEW OF SYSTEMS

Neurologic - Check All That Apply(Required)

Weakness

Seizures

Involuntary Tongue Biting

Fainting/Passing Out

Dizziness

Headaches

Numbness

Restless Leg Syndrome

Shingles

None

Endocrine - Check All That Apply(Required)

Heat Intolerance

Cold Intolerance

Excessive Thirst

Constipation

Cold Hands/Feet

Hyperthyroid

Decreased Libido

Diabetes

Hypothyroid

None

Psyche - Check All That Apply(Required)

Excessive Stress

Memory Loss

Difficulty with Focus

Trouble Concentrating

Hallucinations

Nervousness or Anxiety

Depressed

None

Hematologic/Lymphatic - Check All That Apply(Required)

Iron Deficiency

Folic Acid Deficiency

HIV/AIDS

Hepatitis

None

DENTAL HISTORY

Dental History - Check All That Apply / Have Applied in the Past(Required)

Braces

Orthodontics

Bite Adjustment

Permanent Teeth Removed

Bleeding gums

Painful gums when brush/floss

Treated for gum disease

Lost bone around teeth

Little saliva

Difficulty swallowing food

Sensitive teeth

Broken/chipped teeth

Toothache

Cracked filling

Blisters/sores around/in mouth

None

Bite and Jaw Joint - Check All That Apply(Required)

Problems with your jaw joint

Clench your teeth in the daytime or make them sore

Feels like lower jaw is being pushed back when you bite your teeth together

Wear or have worn bite appliance

Have problems with sleep or wake up with an awareness of your teeth

None

Smile Characteristics - Check all That Apply(Required)

Anything about the appearance of your teeth that you would like to change

Whitened (bleached) your teeth

Feel uncomfortable or self-conscious about the appearance of your teeth

Have you been disappointed with the appearance of previous dental work?

None

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the office of any change in medical status.

Signature(Required)

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The Stewart Center for Optimal Health - 6011 Morriss Rd. Suite 200 Flower Mound, TX 75028 - Phone: 972.874.3957 Copyright© 2019 All Rights Reserved to Hal Stewart, DDS & The Stewart Center for Optimal Health

https://www.thestewartcenterforoptimalhealth.com/wp-content

Useful Links

Child/Adolescent Registration Form A

Child/Adolescent Registration Part A

CHILD/ADOLESCENT ACQUAINTANCE FORM

Parent/Gaurdian

GUARANTOR INFORMATION – IF DIFFERENT FROM ABOVE

MEDICAL INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION

Medical Background Information

FAMILY MEDICAL HISTORY

SOCIAL HISTORY

EARLY CHILDHOOD

SPEECH THERAPY

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS

DENTAL HISTORY

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