Washing Township Dental
New Pediatric Patient Information
Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Patient Information


Mother's Information

Father's Information

Primary Insurance Information

Secondary Insurance Information

The above information is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form are solely my responsibility. We reserve the right to charge for appointments cancelled or failed without 24 hours advance notice. Weekdays after 4PM and Saturdays will automatically be charged. Payment is due in full at time of treatment unless prior arrangements have been approved. Balances unpaid after 90 days are subject to a late charge of 1.5% per month, and may be reported to the credit bureaus at our discretion. I understand that by signing below I accept financial responsibility for all charges whether or not paid by insurance.
Signature of parent/guardian
Relationship to Patient
Date
Washing Township Dental
Pediatric Medical History
Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000


Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus, methicillin resistant staphylococcus aureaus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS


Over the couter rinse School fluoride program
Pediatrician applied fluoride Prescription fluoride toothpaste
Prescripiton drops/tablets/vitamins

The information on both pages of this form is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form is solely my responsibility.
Signature of parent/guardian
Relationship to Patient
Date
Washing Township Dental
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Pediatric Dentistry:
Mary-Kathryn Annuzzi, D.M.D.
Annie Creato, D.M.D.
Additional Pediatric New Patient History (Initial Visit Only)
Supplemental History Questions for Infant/Toddler (4 and under);

Washing Township Dental
HIPAA
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

HIPAA OMNIBUS RULE - Patient Acknowledgement of Receipt of Notice of Privacy Practices and 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.

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment activities, insurance and any other office procedures. A copy of this signed and dated document 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 DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this information with your knowledge and consent.



PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:
I AUTHORIZE Contact from this office to information about my health via:
I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Your comments regarding Acknowledgement or Consents
Office Use Only As privacy officer, I attempted to obtain the pateint's (or representative's) signature on this Acknowledgement, but did not because:
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