Dentistry for Kids

Dr Kris Hendricks
Dr Kelly Hendricks
Dr James Burneson
Dr Steve Tanner
1439 S St Francis Dr, Santa Fe, NM 87505
NEW PATIENT REGISTRATION—
505-473-5437
please print

Patient
Name_______________________________________Preferred Name_____________
Date of Birth:__/__/__ Female___Male___ Current Age_____________
Child’s Social Security Number___________________________________________________
Name of Parent/Guardian filling out form___________________________________________

Mother’s Name_____________________________Marital Status________________________

Mother’s Social Security Number_____________________Mother’s Birthdate______________
Mother’s Employer______________________________Mother’s Work Phone______________
Mother’s Mailing Address________________________________________________________
City_______________________State__________________Zip_________________________
Home Number: __________________ Cell Phone Number:_____________________________
Preferred Contact #(check one): Home___Cell___Email address:________________________
Do you allow us to contact you via email or text to communicate patient information? Y___N___

Father’s Name_____________________________Marital Status________________________

Father’s Social Security Number_____________________Father’s Birthdate_______________
Father’s Employer______________________________Father’s Work Phone______________
Father’s Mailing Address________________________________________________________
City_______________________State__________________Zip_________________________
Home Number: __________________ Cell Phone Number:_____________________________
Preferred Contact #(check one): Home___Cell___Email address:________________________
Do you allow us to contact you via email or text to communicate patient information? Y___N___

DENTAL INSURANCE INFORMATION

If you receive financial assistance for your child’s dental care, please check the option that
applies: Medicaid________CMS__________Project ANN___________Other_____________

Primary Policy Information

Name of Policy Holder: _________________________________________________
Insurance Name: ________________________________Ins phone #____________________
Member ID: ______________________________ Group #______________________
Policy Holderʼs Birthdate _____/_____/___________
Policy Holderʼs Social Security # ______/ _______/_____________(required to file claims)
Employer:____________________________________________________________

Secondary Policy information

Name of Policy Holder: _________________________________________________
Insurance Name: ________________________________Ins phone #____________________
Member ID: ______________________________ Group#______________________
Policy Holderʼs Birthdate _____/_____/___________
Policy Holderʼs Social Security # ______/ _______/_____________ (required to file claims)
Employer:____________________________________________________________
Dentistry for Kids ! Kris W. Hendricks, DDS

Consent for use and disclosure of health information

Section A: Patient Giving Consent

Patientʼs Name

Section B: To the parent or guardian--Please read the following carefully

Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected
health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you
decide whether to sign this consent. Our notice provides a description of our treatment, payment
activities and healthcare operations, uses and disclosures of your protected health information and of
other important matters about your protected health information. A copy of our notice accompanies this
consent. We encourage you to read it carefully and completely before signing.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If
we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain
the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice at
anytime by contacting:
Dr. Kris W. Hendricks
tel. 505-473-5437
fax. 505-438-3443
2904 Rodeo Park Drive East #300
Santa Fe, NM 87505

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of
your revocation submitted to the contact person listed above. Please understand that revocation of
this consent will not affect any action we took in reliance on this consent before we received your
revocation and that we may decline to treat you or to continue treating you if you revoke this consent.
Signature:
I, __________________________________ have had full opportunity to read and consider the contents of this consent
form and Notice of Privacy Practices. I understand that by signing this consent form I am giving my consent to your use
and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Signature _________________________________________ Date _______________

If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representativeʼs Name: __________________________________________
Relationship to Patient: __________________________________________________
Dentistry for Kids ! Kris W. Hendricks, DDS

Dear Responsible Party: The following descriptions of treatment aids may possibly be used by
Dr. Hendricks in caring for your child. We will discuss with you their use when applicable.

Nitrous Oxide/Oxygen - This gas mixture is administered through a nose mask; its main purpose is to help reduce
anxiety, although it also reduces the perception of pain. Patients do not go to sleep as they are always receiving at least
40% oxygen. Very rare side effects might include nausea, vomiting and dizziness. The effects of the gas end within
minutes after stopping its use.

Local Anesthesia - This may be in the form of a topical gel/cream or an injectable liquid. It is used to produce anesthesia
of the hard and soft tissues. Allergies are rare, but could include rash, skin eruptions and anaphylactic shock, which could
be deadly without prompt medical management. Children must be constantly reminded not to bite or chew on the soft
tissue in the anesthetized area.

Rubber dam application - This consists of a clamp that fits over the tooth and a thin piece of rubber that isolates the
teeth being treated. It enables us to do a better job of restoring your childʼs teeth and protects your child from exposure to
the materials used in that process.

Fluoride treatment - may be used based on the childʼs dental history and past exposure to other fluorides.

Extractions - Removal of teeth.

Composite fillings - tooth colored resin fillings.

Stainless steel crowns - used when the tooth is too badly decayed to hold a filling.

Sealants - a thin coating of resin is placed on the biting surfaces of the teeth to prevent decay from starting. The teeth
must be cleaned and etched with a mild acid before the sealant is placed. Occasionally some decay is discovered. This
requires the placement of a preventative resin restoration, for which a separate fee is charged.

Protective stabilization and gentle restraint - used only when necessary to protect your child and/or the dental team.

Please sign below if you agree to the following statements:

I am informed that in most cases if I fail to keep an appointment without giving the office 24 hoursʻ notice, I will not be
granted priority rescheduling.
I am advised that although good treatment results are expected, there can be no guarantee expressed or implied as to the
result of treatment or cure.
I understand that, although adverse reactions to routine dental care are rare, they can occur. Adverse reactions may
include nausea, vomiting, dizziness, breathing difficulty, allergic reactions, excess bleeding and prolonged numbness. I
understand that any of these adverse reactions may require hospitalization and could lead to death.

I authorize Dr. Hendricks and his staff to take the radiographs (x-ray films) necessary to provide good dental care and
expect to be informed before any radiographs are taken. If I do not agree to radiographs, a separate form will be
provided, releasing the doctors from certain liabilities.

Signed ___________________________________________ Date ________________

 WE LOVE ON TIME PATIENTS!!!!

Here at Dentistry for Kids we try our very best to keep our
schedule running on time, and you as the patients can help us
by arriving a few minutes early to your appointment.

When patients are even slightly late it can throw off our
schedule for the whole day.
So—if you are five minutes late we MAY have to reschedule your
appointment. We will do our best to see you, but we have to
prioritize other patients who are on time that day. If you are
ten minutes late or more we will try to find a later opening on
the schedule for you that day, or if the schedule is too full we
will gladly help you reschedule for another day.

We do our best to see each and every patient, so let us know if

something unexpected comes up and we will do what we can to
accommodate you.

We totally get that life happens—communicate with us and we’ll

do our best to take care of you!

I have read and understand the Dentistry for Kids attendance

policy:

________________________________________________________________________Date:_________________
Dentistry for Kids ! Kris W. Hendricks, DDS

Financial Policy

Your childʼs dental care is our primary objective. Our professional relationship depends on your clear
understanding of our financial policy as well as of your own insurance plan, if applicable.

Payment is due at time of service. If you have dental insurance, as a courtesy to you, we will submit your
claims. Since our patients represent over 350 insurance companies, we canʼt be experts on everybodyʼs
policy. It is your responsibility to be familiar with your own policy. If you have questions or confusion, please
call your insurance company directly so that there are no surprises.

We have contracts with Dental Source, United Concordia, most Delta Dental plans, and all forms of Medicaid.
For other insurance companies we ask you to pay 25% of the dayʼs services as well as gross receipts tax after
your appointment. This will be an estimate. We will then bill your insurance and if the insurance company
pays out more than expected we will reimburse you. If the insurance company pays less, then we will send
you a statement for the remaining balance.

Once we send out a claim, insurance companies are required by law to make a determination on it within 45
days of receiving it. You will then be notified of any balance that is due. We expect payment of that balance
within 30 days of notification. Your dental insurance is a contract between you and your insurance company,
not this office. We will not become involved in disputes between you and your insurance company, other than
to supply factual information as needed.

This office will not become involved in marital or family disputes. The person designated as the responsible
party--the one making appointments and bringing the patient to appointments--will be sent all relevant
communications, including bills. That individual is responsible for the payments of bills. This person will also
receive our phone calls and notices of payment due, regardless of court settlements or personal arrangements.

If someone other than a parent brings a child into an appointment, we need to have a signed parental consent
form, authorizing this office to treat the child, before the child can be seen.

We accept as payment: cash, checks, all major credit cards as well as the Care Credit health care credit card.
If you have questions about applying for Care Credit, please see our front desk staff.

Other Service Charges:

*18% Annual (1.5% monthly) interest is charged to accounts with outstanding balances 60 days from date of
service.
*Returned checks are subject to a $25 service charge.
-------------------------------------------------------------------------------------------------------------------------------

I have read this policy statement and hereby agree to the conditions herein

(Signed)__________________________________________________(Date)______________
Dentistry for Kids ! Kris W. Hendricks, DDS

Patient Name______________________________________________ Account #________________

Is this your childʼs first visit to a dentist? __Yes __No
Was previous experience __good __bad __other Explain__________________________________________
How did you find us? Internet___ Phone Book (which one?)__________ Ad___Friend___Other____________
Please tell us the main reason for todayʼs visit___________________________________________________
Has your child been experiencing dental pain? __yes __no
Has your child been awake at night from dental pain? __yes __no
Do you have any concerns about your childʼs dental health?________________________________________
Has your child ever been hospitalized? __yes __no If yes please give date & reasons____________________
Is your child allergic to any medications? __yes __no Please identify_________________________________
Is your child currently taking any medications? __yes __no Please identify_____________________________
Reason for the medication_________________________ Pediatrician name & phone____________________
Has your child had: DPT immunization __yes __no Polio vaccine __yes __no Measles Mumps & German
measles __yes __no
Is there anything you can tell us about your child that could assist us in taking the best possible care of them?
________________________________________________________________________________________
Does your CHILD now have or have they ever had in the past: (please circle y or n)

Speech problems Y N Anemia/Sickle Cell Disease Y N Cerebral Palsy Y N

Hearing problems Y N Bruises Easily Y N Seizures Y N
Asthma Y N Blood Transfusion Y N Kidney/Bladder problems Y N
Skin problems Y N Hepatitis/Jaundice Y N Diabetes Y N
Allergies (other) Y N Cystic Fibrosis Y N Pregnancy (patient) Y N

Please Identify Allergies_____________________________________________________________________

Has patient had heart disease or a heart murmur Y N Please describe_______________________________
Is pre-medication required for dental treatment? Y N Drug preferred_______________Childʼs Weight______
Please circle all illnesses your child has previously had:
Chickenpox Earaches Measles German Measles Mumps Mononucleosis HIV/AIDS
Scarlet Fever Tuberculosis Venereal Disease Tonsillitis
Learning/Behavior Disorders Y N Please describe_______________________________________________
Has your child had any prior surgeries? Y N Is your child currently scheduled for surgery? Y N Date?_____
Please describe___________________________________________________________________________
Is there anything else we should know about your child?

Parent/Guardian Signature_______________________________________________Date________________