Christopher Callan, DMD, MS - Dr. Sheldon Waltuch, DMD, MS
NJ SP#6776 - NJ SP#3106
Patient Information
Today's Date:
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Male
Female
Other
Preferred Pronouns
He/Him
She/Her
They/Them
Address:
City:
State:
Zip:
Primary number for appointment confirmations:
Email:
Who referred you to our office?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Guardian (1)
First Name:
Middle Initial:
Last Name:
Gender:
Male
Female
Relationship:
Social Security #:
Birthdate:
Primary Phone #:
Type:
H
C
W
Secondary Phone #:
Type:
H
C
W
Email:
Check if address is the same as the patient's listed above.
Address:
City:
State:
Zip:
Guardian (2)
First Name:
Middle Initial:
Last Name:
Gender:
Male
Female
Relationship:
Social Security #:
Birthdate:
Primary Phone #:
Type:
H
C
W
Secondary Phone #:
Type:
H
C
W
Email:
Check if address is the same as the patient's listed above.
Address:
City:
State:
Zip:
Dental Insurance Information
Primary Coverage
Policyholder's Name:
Policyholder's Birthdate:
Social Security #:
Member Id #:
Insurance Company:
Group #:
Employer's Phone #:
Secondary Coverage
Policyholder's Name:
Policyholder's Birthdate:
Social Security #:
Member Id #:
Insurance Company:
Group #:
Employer's Phone #:
Dental History
Dentist Name:
Has the patient ever had an orthodontic consult/treatment:
No
Yes
Main orthodontic concern?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Speech problems/therapy?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently chews gum?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Have wisdom teeth been removed?
No
Yes
Is all dental work completed at this time?
No
Yes
Grind or clench teeth?
No
Yes
Oral habits (thumb/finger habit, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Frequent sore thoats?
No
Yes
Frequent headaches?
No
Yes
Issues with food stuck between teeth?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Teeth that irritate tongue, cheeck, lip?
No
Yes
Bad taste/mouth odor?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Medical History
Patient's Doctor:
Phone #:
Date of Last Exam:
Is the Patient current with Immunizations?
No
Yes
Current Medications:
History of hospitalization or surgery:
Allergies/Sensitivities:
Phobias:
None of the above
DIAGNOSIS/TREATMENT
Check all that apply
ADHD/ADD
Asthma
Autism Spectrum
Diabetes
Tuberculosis
Brain Injury
Acid Reflux
Special Needs
Cleft Lip/Palate
Cardiac Disease/Heart
Bladder/Kidney
Earaches/Infections
Speech Disorder/Delay
Delayed Development
Muscular Disorder
Depression/Anxiety
Thyroid Disorder
Stomach/GI Disorder
Hepatitis/Liver Disease
Arthritis/Joint Disorder
Down's Syndrome
Rheumatic Fever
Cystic Fibrosis
Cancer/Malignancy
Tobacco Use
Gag Reflex
Eating Disorder
Immune Disorder
Bone Disorder
Epilepsy/Seizure
Cerebral Palsy
TMJ Problems
Sensory Issues
Pregnancy
HIV/AIDS
Hearing/Vision Problems
Anemia/Blood Disorder
Abnormal Bleeding/Hemophilia
Cognitive/Social Delay
Premature/Low Birth Weight
Chemo/Radiation Therapy
Emotional/Behavioral Issues
Hearing/Visual Impaired
Heart Murmur/Defect/Surgery
Other:
If yes to any of the above, please detail:
Financial Policy
Payment Due:
The outstanding amount on the account is due at the time specified in the original contract, unless previous claims are outstanding on the account. In the event of underpayment, after insurance has paid for treatment, the balance is the responsibility of the parent or guardian immediately after receiving a statement. For your convenience we accept cash, check, debit and credit cards. In the event of overpayment, you will be reimbursed by check in the mail unless you decide to keep the credit on your account for future visits.
Statements:
If you have a balance on your account, we will send you a statement in the mail to the address we have on file for the parent or guardian. It will show your current and previous balance. It will not reflect any details regarding what you insurance company paid, deductibles, percentage of coverage, limitations or frequency, etc.., those details will come in the Explanation of Benefits from your insurance provider(s). We are on a 30-day billing cycle.
Past Due Accounts:
Unless prior arrangements have been approved in writing by our office, the outstanding balance on your statement is due at the time specified in the original treatment contract. If necessary, accounts that are not paid on within ninety (90) days will be referred to our collection department. If balance is not met, the responsible party(ies) will be assume the cost of collections, including court costs.
Insurance:
We are happy to file dental claims for our families who have dental insurance.
Filing your insurance claim is not a guarantee of payment.
Please understand that the contract for dental insurance is between you and your insurance company. Any dispute of coverage needs to be handled through the insurance company directly by you. The parent or guardian has the final responsibility for payment of any services rendered. Our doctor’s recommend treatment based on your child’s needs, not on what insurance will pay. Therefore, we will do everything possible to maximize your benefits. It is your responsibility to provide us with the most accurate dental insurance information and update it as necessary. Accurate and complete insurance information must be provided so we may assist you in filing your claim promptly. Most insurance coverage will be verified before your insurance company can be billed. In the event that your insurance has not paid your account within ninety (90) days, the balance may be transferred to your account. We reserve the right to discontinue or refuse to file a claim. In some instances insurance plans will make payments directly to the member and payment in full will be collected on the day that treatment is provided.
Divorce/Separation:
The parent or guardian who signs the contract is responsible for payment independent of what a divorce decree or custody arrangement may state. Reimbursement must be made between the divorced parents. We will not intervene.
Returned Checks:
There is a $35 fee for any checks returned by the bank.
Initial:
Appointment Policy
Appointment Time:
Please keep in mind, one of our goals is providing dentistry that is as pleasant as possible for your child and that a dental appointment is an excused absence from school. We value your time in scheduling the sufficient time needed for each appointment and it’s very important that you have your child in the office at the time scheduled. If you are more than 10 minutes late, it may be necessary to reschedule your child’s visit.
Cancelling or Rescheduling:
We request that cancellations are made 48 hours prior to the appointment. In doing this, appointment time may then be made available to another family. Two (2) broken appointments or “no shows” may affect future scheduling at another time.
I have read the above policies and understand my obligations with Waltuch and Callan Orthodontics for my child’s dental care. I affirm that my signature represents my agreement to all of the terms and conditions mentioned above and the agreement will be in full force and effect.
Guardian Signature:
Date:
Acknowledgement of Receipt of Notice of Privacy Practices
I,
, have received a copy of this office's
Notice of Privacy Practices
.
Patient Name:
Parent/Guardian Signature:
Date:
Waltuch and Callan Orthodontics may leave protected Health Information, including patient’s name, diagnosis, date & time of service/appointment, on the following (please check appropriate and include number:
Answering machine/voicemail:
Text message:
Email:
Other:
This section is used to obtain authorization to release information regarding you and/or your child covered under the Privacy Act to people other than yourself.
I,
, authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself
and/or my child(ren).
Name:
Relationship:
Phone Number:
Name:
Relationship:
Phone Number:
Name:
Relationship:
Phone Number:
Authorization & Release
To the best of my knowledge, I have accurately answered the questions on this form. I understand that providing incorrect information can be dangerous to the patient's health. It is my responsibility to inform the dental office of any changes in the patient's medical status. I also authorize the dental staff to perform all necessary dental services the patient may need, including guidelines outlined by the AAO for routine radiographs. I understand that Waltuch and Callan Orthodontics may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand that I am responsible for the full balance of the account regardless of my dental benefits and directly assign Waltuch and Callan Orthodontics all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. I affirm that my signature represents my agreement to all of the terms mentioned above.
Signature:
Relationship to child:
Date: