Please tell us about your child.

This provides the dentist with important information required for their Dental treatment and Oral Health Care.

Dental History

Has your child ever had:

Teeth Brushing Habits

How did you hear about us?

Covid Risk Assessment

Does your child or any member of the household have any of these symptoms: a high temperature or a new continuous cough?

Any other uncommon symptom of fever, sore throat, cold, runny nose, diarrhoea, stomach issues, headaches, aches and pains, shortness of breath sneezing, loss of taste, loss of smell or fatigue?

Did you or any member of the household return from abroad in the last month?

Is anyone in the household Covid positive or waiting for the test results?

Authorisation & Release

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 child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I hereby authorise Happy Kids Dental to perform the examination and, after explanation if needed and further consent given by parent, any and all treatment for the above-named child including radiographs if indicated and consent to such methods, drugs and agents that may be indicated in connection with his/her dental care as well as contacting me with detail of appointments time, planned treatment cost and appointment reminders via email, phone call and/or text message. This consent shall remain in effect until cancelled. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

Notice of Privacy Practices - How we may disclose your PHI (personal health information)

Heath Care Operations: We may use and disclose your PHI including x-rays, clinical photographs and clinical information for our own health care operations and other health care professionals involved in the provision of healthcare to you.

Business Associates: There are some services provided to our organisation through contracts with business associates, such as laboratory, dental practices or radiology services. We may disclose your PHI to our business associates to enable them to provide their services.

Individuals Involved with Your Care: We may disclose your PHI to family or others identified by you or who are involved in your care or payment for your care.

Legally Required Disclosures & Public Health: We may disclose your PHI as required by law, including to government officials to prevent or control disease, to report child, adult or spouse abuse, to report reactions or problems with products and to report deaths.

Payment: We may use and disclose your PHI to billing and collection agencies, insurance companies and health plans to collect payment for our services.

Changes to this notice: Please note that this consent can be withdrawn at any time

Please type your name in BLOCK CAPITALS

Patient-only offers

Occasionally we organise patient-only events, provide discounts on current treatments or launch new innovative treatments. If you would like to be the first to know about our exclusive patient-only offers, please indicate how you would prefer to hear from us. Please note, you can unsubscribe from any type of communication at any time.

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