1. health and fitness
2. dental care

Heidi J. Stark, D.D.S.
Diplomate, American Board of Pediatric Dentistry
J’
Libby A. Johnson, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Emily J. Egley, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Katie J. Garcia, D.D.S.
Thank you for selecting Lincoln Pediatric Dentistry for your child’s dental care!
•
Your child’s initial appointment will take approximately 40-60 minutes.
Please arrive 15 minutes early in order to process your child’s health and
insurance information.
•
Please complete the Patient’s Registration and History form prior to arriving
at our office. This form may be mailed or faxed to us ahead of time. If
your forms are not filled out completely by your appointment time, you may
be asked to reschedule.
•
Every effort is made to schedule a time that will work for you. If, for some
reason, you are unable to keep this appointment, we require at least 24 hours
advance notice. If no notice is given and you have missed the appointment,
you will not be allowed to reschedule.
•
If, for any reason, you are 10 minutes late for any appointment, we may ask
that you reschedule for another day or time.
•
If there is a language barrier, please bring an interpreter in order to
understand your child’s treatment and any financial obligations.
For additional information on Drs. Stark, Johnson, Egley, and Garcia, “What to
expect at your child’s first visit”, and our “Financial Policy”, please read the
practice brochure or visit our website.
North Location:3272 Salt Creek Cr., Ste. A, Lincoln, NE 68504 (402) 476-1500 Fax (402) 476-1510
Southeast Location: 4301 S. 80th St., Lincoln, NE 68516 (402) 476-4301 Fax (402) 476-4305
www.lincolnpediatricdentistry.com
Heidi J. Stark, D.D.S.
Dr. Heidi Stark is a native of Lincoln and received her dental
degree from the University of Nebraska Medical Center.
She completed her Pediatric Dental Residency at Children’s
Memorial Hospital of Northwestern University in Chicago, IL.
2 LOCATIONS
3272 Salt Creek Circle, Suite A • Lincoln, NE 68504
(402) 476-1500 • Fax (402) 476-1510
4301 S. 80th St. • Lincoln, NE 68516
(Southwest corner of 80th & Pioneers Blvd)
402-476-4301 • Fax 402-476-4305
www.lincolnpediatricdentistry.com
Libby A. Johnson, D.D.S.
North Location
Dr. Libby Johnson grew up in Sioux Falls, South Dakota. She
received her dental degree from the University of Nebraska
Medical Center in 2009. She completed her pediatric
residency program at UNMC in Omaha, and started
practicing at Lincoln Pediatric Dentistry in July 2011.
I-80
Fletcher Ave.
W
Katie J. Garcia D.D.S.
Diplomate, American Board of Pediatric Dentistry
Emily J. Egley, D.D.S.
Diplomate, American Board of Pediatric Dentistry
If coming from the South:
1.
2.
3.
4.
5.
Drive north on 27 th Street to Superior Street.
Turn right on Superior Street and go 1.57 miles.
Turn left on North 33 rd Street and go 0.8 miles.
Turn left on Salt Creek Circle past the NHA building.
We are the third building on the right.
If coming from the North:
1.
2.
3.
4.
5.
6.
Take Exit #403/27 th Street Exit from Interstate 80.
Turn south on N. 27 th Street and go 0.66 miles.
Turn left on Fletcher Avenue and go 0.56 miles.
Continue on N. 33 rd Street and go 0.3 miles.
Turn right on Salt Creek Circle before the NHA building.
We are the third building on the right.
Dr. Katie Garcia grew up in Lincoln, NE. She graduated from
the University of Nebraska-Lincoln in 2005 and received
her Doctor of Dental Surgery degree from the University of
Nebraska Medical Center, College of Dentistry in 2010. She
then completed a general practice residency at Peninsula
Hospital in Queens, New York. Dr. Katie completed her pediatric
dental residency at Ann and Robert H. Lurie Children’s Hospital
of Northwestern University in Chicago, IL in June 2013.
Southeast Location
Van Dorn St.
Pioneers Blvd.
S. 70th St.
Dr. Katie is a member of the American Academy of Pediatric
Dentistry and American Dental Association. She enjoys playing
tennis and golf, snowboarding, traveling to new places,
and spending time outside playing with her dog, Oliver.
Libby A. Johnson, D.D.S.
Old Cheney Rd.
84th St.
Dr. Emily is a member of the American Academy of Pediatric
Dentistry, American Dental Association, Nebraska Dental
Association, and Lincoln District Dental Association. She
married her husband, Josh, in the summer of 2011. Their
son, Emmett, was born in October 2012. She enjoys cooking,
gardening, reading, yoga, and being a mom.
Superior Street
S. 80th St.
Dr. Emily Egley is originally from Blue Springs, Missouri. She
came to Nebraska to attend UNL. She graduated from the
University of Nebraska in 2006, UNMC College of Dentistry in
2010 and the UNMC Pediatric Dental residency program in
2012.
N. 27th Street
Emily J. Egley, D.D.S.
Salt Creek Circle
Diplomate, American Board of Pediatric Dentistry
E
S
N. 33rd Street
North Star
High School
Dr. Libby is a member of the American Academy of Pediatric
Dentistry, American Dental Association, Nebraska Dental
Association, and the Lincoln District Dental Association. She
and her husband, Andrew, enjoy watching Husker football,
golfing, and spending time with friends and family. They
welcomed their daughter, Georgia, in August 2012.
Heidi J. Stark, D.D.S.
N
Lucile Dr.
Dr. Heidi is a Diplomate of the American Board of Pediatric
Dentistry and has been elected a Fellow of the International
College of Dentists and American College of Dentists. She is
a member of the American Academy of Pediatric Dentistry,
American Dental Association, Nebraska Dental Association,
Lincoln District Dental Association, and American Academy
of Pediatrics. She is a board member of the Lincoln Lancaster
County Health Department and Heart to Honduras. She serves
on health advisory committees for ExCite and HeadStart. She
and her husband, Todd, have two children. They are active
in the community, their church, and with mission work in
Honduras.
Katie J. Garcia, D.D.S.
North Office
3272 Salt Creek Circle, Suite A
Lincoln, Nebraska 68504
(402) 476-1500
Fax (402) 476-1510
Southeast Office
4301 S. 80th St.
Lincoln, NE 68516
(402) 476-4301
Fax (402) 476-4305
www.lincolnpediatricdentistry.com
Welcome to our practice
We are pleased that you have chosen our office
to provide dental care for your child. Our goal is
to help your child achieve a healthy smile and
remain cavity free. We want to educate you and
your child so that he/she will grow up having a
positive dental experience that can be passed on
to family and friends.
Our office is specially designed to treat infants,
children, teenagers, and patients with special
needs. You will find that our staff is trained to
understand the concerns and needs of children
and their parents. We want your child to leave
our office feeling good about the experience
and understanding the importance of good oral
hygiene. We are confident you will find Dr. Heidi, Dr.
Libby, Dr. Emily, Dr. Katie and our staff to be caring,
competent, and gentle. We are always willing to
answer any of your questions or concerns.
The benefit of a dental visit
by age one
The American Academy of Pediatrics and
American Academy of Pediatric Dentistry
recommend children have their first dental visit
when the first tooth comes in, usually between six
and twelve months of age.
Establishing a dental home by age one
prevents decay because of early education
and preventative care. In addition, parents can
anticipate what to expect in their child’s dental
development.
Also, if your child has a dental emergency, they will
be more comfortable in our office and we will be
familiar with your child.
What to expect at your
child’s first visit
Your child’s first dental visit will include a medical
history review and a thorough dental exam. The
dental exam will be an evaluation of the teeth and
gums, a head and neck exam, and a preliminary
orthodontic evaluation.
Dr. Emily • Dr. Katie • Dr. Heidi • Dr. Libby
What is a Pediatric Dentist?
Pediatric dentists evaluate, treat, and maintain the
tissues and structures of the mouth from infancy
to adolescence. Pediatric dentists complete
two additional years of specialized training
following dental school, which includes study
in child psychology, growth, and development.
Our dentists are trained and qualified to care
for patients with special medical, physical, and
mental needs.
Their training allows us to provide the most upto-date treatment for a wide variety of children’s
dental problems, which include, but are not
limited to: cavities, crowded and/or crooked teeth,
and emergency care for chipped, fractured, or
knocked out teeth.
Your child will receive a cleaning and fluoride
treatment. Digital x-rays may be taken based on the
child’s needs. Our dentists will develop a diagnosis
and treatment plan and will discuss the findings with
you at the end of the appointment.
We find by age 3 most children like to come back
to the treatment area by themselves and enjoy their
independence. We encourage this, as we continue
to develop a relationship with your child. We spend
time talking with them and showing them photos of
cavities, plaque, dental floss and healthy teeth. We
also teach them how to brush with adult supervision
at our child size brushing stations. You will be
given a tour of the office following your child’s first
appointment, prior to visiting with Dr. Heidi, Dr. Libby,
Dr. Emily, or Dr. Katie.
Preparing your child for
their first dental visit
If your child’s first visit is after age one or they
have had a previous bad experience, you can
talk to your child about their dental visit. Keep
it simple and positive by telling them they will
get their teeth counted and receive a new
toothbrush, and maybe even have pictures
taken of their teeth. Please do not use scary
words or talk about your anxiety because
children can become unnecessarily afraid.
About our offices
Our offices are decorated with a lodge theme
and split log siding, bears, and our familiar
moose. You will enjoy spacious treatment areas,
a comfortable reception area, play rooms, and
large windows that all provide a very open feel.
Financial Policy
Payment is due at the time dental services
are provided. As a courtesy, we will bill your
insurance company for their portion. We accept
cash, checks, Visa, MasterCard or Discover.
An alternative, CitiHealth, is a healthcare credit
system which allows interest free payments for
up to one year. Applications are available online
at www.healthcard.citicards.com, or from
our financial coordinator.
Heidi J. Stark, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Libby A. Johnson, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Emily J. Egley, D.D.S.
Diplomate, American Board of Pediatric Dentistry
PATIENT’S
PATIENT’S
REGISTRATION
REGISTRATION
AND HISTORY
AND
HISTORY
PATIENT’S
REGISTRATION
AND
HISTORY
Katie J. Garcia, D.D.S.
IN ORDER
ININ
ORDER
TO
PROVIDE
TOTO
PROVIDE
THE BEST
THE
AND
BEST
SAFEST
AND
SAFEST
COMPREHENSIVE
COMPREHENSIVE
DENTAL
DENTAL
CARE CARE
FOR
YOUR
FOR
YOUR
CHILD
CHILD
WE
ARE
WE
ARE
ORDER
PROVIDE
THE
BEST
AND
SAFEST
COMPREHENSIVE
DENTAL
CARE
FOR
YOUR
CHILD
WE
ARE
THANKING
THANKING
YOU IN
YOU
ADVANCE
ININ
ADVANCE
FOR COMPLETING
FOR
COMPLETING
OUR DETAILED
OUR
DETAILED
MEDICAL
MEDICAL
HISTORY
HISTORY
FORM FORM
THANKING
YOU
ADVANCE
FOR
COMPLETING
OUR
DETAILED
MEDICAL
HISTORY
FORM
PLEASE
PLEASE
PRINT
PRINT
INPRINT
BLUE
ININ
OR
BLUE
BLACK
OR
BLACK
INK
INK
PLEASE
BLUE
OR
BLACK
INK
hild’sChild’s
Name
Name
______________________________________________________
______________________________________________________
Preferred
Preferred
NameName
____________________________
Child’s
Name
______________________________________________________
Preferred
Name____________________________
____________________________
First
FirstFirst
MI
MI MI Last
Last
Last
thdate
Birthdate
_____________________________________
_____________________________________
Age__________
Age__________
SS#__________________________
SS#__________________________
Gender
Gender
M
FM M F F
Birthdate
_____________________________________
Age__________
SS#__________________________
Gender
ddress
Address
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Address
________________________________________________________________________________________________________
y____________________________________________________________
City____________________________________________________________
State____________
State____________
Zip Code
ZipZip
Code
______________________
______________________
City____________________________________________________________
State____________
Code
______________________
me Home
Phone________________________________________
Phone________________________________________
Primary
Primary
Language
Language
Spoken
Spoken
__________________________________
__________________________________
Home
Phone________________________________________
Primary
Language
Spoken
__________________________________
hild primarily
Child
primarily
lives with
lives
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with
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that
apply):
____Mother
____Mother
____Father
____Father
____Stepmother
____Stepmother
____Stepfather
____Stepfather
Child
primarily
lives
with
(check
all
that
apply):
____Mother
____Father
____Stepmother
____Stepfather
____Grandparent
____
Foster
parent/guardian
parent/guardian
____other
____other
home home
Grandparent
____Foster
____
____
Foster
parent/guardian
____other
home
Grandparent
____
easePlease
check
check
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as
or or
itnoapplies
asas
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yourtochild:
your
child:
Please
check
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child:
YES NO
NOYESYESNONO
YES NOYESYESNONO
YES NOYESYES
NONO
YES
YES NO
YES NO
YES
NO
❑ ❑ ❑Child
Abuse
❑ ❑ ❑Injury
toInjury
Front
toTeeth
Front
Teeth
❑ ❑ ❑ADD/ADHD
❑ ❑ Abuse
❑Child
Child
Abuse
❑❑❑
Injury
to
Front
Teeth
❑ ❑ ❑ADD/ADHD
ADD/ADHD
Brain
MRSA
  ADD/ADHD
 
  Epilepsy/Seizures
 
❑ Injury
❑ ❑Cleft
Palate/Lip
❑ ❑ ❑Kidney
Kidney
Disease
AttentionAttention
Deficit
Disorder
Deficit
Disorder
/ Attention
/ Attention
❑ ❑Palate/Lip
❑Cleft
Cleft
Palate/Lip
❑ ❑ ❑Disease
Kidney
Disease
Attention
Deficit
Disorder
/ Attention
Palsy
Conditions ❑ ❑ ❑Lung
MSPI
  Adopted
Disorder
 Cerebral
 Sores
 Eye
❑ Disease

❑ ❑
❑Cold
Sore/Canker
Sores
Lung
Disease
Deficit Hyperactivity
Deficit
Hyperactivity
Disorder
❑ ❑Sore/Canker
❑Cold
Cold
Sore/Canker
SoresImpairment
❑
❑
Lung
Disease (Patient)
Deficit
Hyperactivity
Disorder
AIDS/HIV
Chemical
Dependence
Hearing
Pregnancy
❑ ❑ ❑




❑ ❑ ❑Developmentally
❑ ❑Developmentally
DelayedDelayed
❑ ❑ ❑Mentally
❑ ❑Mentally
Handicapped
Handicapped
AIDS/HIV
❑ ❑AIDS/HIV
❑
Developmentally
Delayed
❑
Mentally
Handicapped
❑
AIDS/HIV
Birth
  Allergy to Augmentin
  Chemo/Radiation
  Heart Disease/Cond
  Premature
Age level
Age
patient
level
is
patient
at
_____
is at
_____
❑ ❑ ❑Metallic
❑ ❑Metallic
Implant,
Implant,
Shunts,
Shunts,
Pins/Rods
Pins/Rod
❑ ❑ ❑Asthma
❑ ❑Asthma
Age
level
patient
is
at
_____
❑
Metallic
Implant,
Shunts,
Pins/R
❑
Asthma
  Allergy to Latex
  Chicken Pox
  Heart Murmur
  Psychiatric Care
❑
❑
❑
Diabetes
❑
Diabetes
❑
❑
❑
Premature
❑
Premature
Birth
Birth
❑
❑
❑
Autism
❑
Autism
❑
❑
Diabetes
❑
❑
Premature
Birth
❑
❑
Autism
  Allergy to Peanuts
  Child Abuse
  Innocent Heart Murmur   Juvenile Rheumatoid Arthritis
❑ ❑Earaches/Ear
Infections
❑ ❑ ❑Prolonged
❑ ❑
Prolonged
Bleeding
Bleeding
When
Cut
When
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Behavioral
Problems
Problems
❑ ❑ ❑Earaches/Ear
Earaches/Ear
❑
Prolonged
Bleeding
When
❑ ❑ ❑Behavioral
Behavioral
Problems
SBE Required
Allergy-Omnicef/Ceph
Due to Heart Condition
❑ ❑ ❑
  Cleft❑Palate/Lip
 Infections
Infections
❑
❑
❑
Epilepsy/Seizure
❑
Epilepsy/Seizure
Disorder
Disorder
❑
❑
❑
Psychiatric
❑
Psychiatric
Care
Care
❑
❑
❑
Birth
❑
Defects
Birth
Defects
❑
❑
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Disorder
❑
❑
Psychiatric
Care
❑
❑
Birth
Defects
  Allergy to Pen/Amox
  Cold/Canker Sores
  SBE/Antibiotic required   Shunts-Explain _______
❑ ❑ ❑Eye
Conditions
❑ ❑ ❑Rheumatic
❑ ❑
Rheumatic
Fever
Bleeding
Gums
Gums
❑ ❑Conditions
❑EyeEye
Conditions
❑
Rheumatic
Fever
❑ ❑ ❑Bleeding
Bleeding
Gums   Depression
Sickle Fever
Cell
Disease
Allergy-Seasonal
❑ ❑ ❑

 Hemophilia
❑ ❑ ❑Females:
❑ ❑Females:
Are
you
pregnant?
youyou
pregnant?
❑❑
Cell
Sickle
Disease
CellCell
Disease
Blood
Transfusions
Blood
Transfusions
Sickle
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Trait
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Meds
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❑Delay
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❑
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❑❑❑
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
❑ ❑ ❑
  Developmental
 Are

❑ ❑ ❑Hearing
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❑ ❑ ❑Sore
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❑ ❑ ❑
  Motor
Impairment
 High Blood Pressure
❑ ❑ ❑Hearing
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❑
❑
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❑ ❑ ❑Bone/Joint
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❑ ❑ ❑Heart
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❑ ❑ ❑Speech
❑ ❑
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Autism/Asperger’s
❑ ❑ ❑
  Speech
Disease
 Injury - Front Teeth
❑ ❑ Injury
❑Brain
Brain
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❑ ❑ Disease
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Heart
❑
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Tuberculosis
Behavioral
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❑ ❑ ❑Heart
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❑ ❑ ❑
  Cognitive
Murmur
 Kidney Disease❑ ❑ ❑Thyroid
❑
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❑ ❑ ❑Cerebral
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Birth
❑ ❑ ❑
  Diabetes
  Liver Disease ❑ ❑ ❑Tonsillitis
❑ ❑
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Chemical
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❑ ❑ ❑Hemophilia
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❑ ❑ ❑Hepatitis/Liver
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Bone/Joint
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Metal
Implant/Pins/Rods


❑ ❑ ❑




❑ ❑ ❑Tumor,
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Chicken
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PoxPox
❑ ❑ ❑High
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❑ ❑ ❑Cancer
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❑ ❑ ❑Chicken
Chicken
❑ ❑Blood
❑High
High
Blood
Pressure
Child'sChild's
Medical
Medical
Doctor______________________________Phone:_________________________
Doctor______________________________Phone:_________________________
Date of
Date
last
of
exam
last
exam
____________
__________
Child's
Medical
Doctor______________________________Phone:_________________________
Date
of
last
exam
________
your
child
presently
under
the
care
of
a
physician
or
specialist
for
any
reason?
Is yourIschild
presently
under
the
care
of
a
physician
or
specialist
for
any
reason?
YES
NO
Is your child presently under the care of a physician or specialist for any reason?
ExplainExplain
__________________________________________________________________________________________________
________________________________________________________________________________________________
Explain
______________________________________________________________________________________________
Name
_______________________________________
___________________________________________
DoctorDoctor
Name
_______________________________________
PhonePhone
____________________________________________
Doctor Name
_______________________________________
Phone
_________________________________________
YES
NO
Is yourIschild
your
taking
child
taking
any
medications?
any
medications?
Is your child taking any medications?
List ______________________________________________________________________________________________________
ListList_____________________________________________________________________________________________________
___________________________________________________________________________________________________
YES
NO
Does
your
child
have
any
allergies
toto
medicines,
latex,
foods,
or or
metals
not
listed
above?
Does your
child
have
any
allergies
to medicines,
latex, foods,
orfoods,
metals
not
listed
above?
Does
your
child
have
any
allergies
medicines,
latex,
metals
not
listed
above?
List ______________________________________________________________________________________________________
ListList_____________________________________________________________________________________________________
___________________________________________________________________________________________________
Are antibiotics
AreAre
antibiotics
necessary
necessary
prior to prior
dental
to work
dental
because
work
because
of
a heart
of of
amurmur,
heart
murmur,
defect,
defect,
prosthesis,
prosthesis,
shunt, orshunt,
other
ormedical
other
medical
reason?
reason?
YES
NO
antibiotics necessary
prior
to
dental
work
because
a heart
murmur,
defect,
prosthesis,
shunt,
or
other
medical
reason?
ExplainExplain
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Explain
_______________________________________________________________________________________________
YES
NO
Has your
Has
child
your
been
child
hospitalized,
been
hospitalized,
sedated,
sedated,
or hadorsurgery?
had
surgery?
Has your child been
hospitalized,
sedated,
or
had
surgery?
ExplainExplain
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Explain
_______________________________________________________________________________________________
Has any
Has
member
any
member
of the of
family,
the
family,
including
including
your child,
your
had
child,
a had
problem
a problem
with sedation
with
sedation
or general
or or
general
anesthesia?
anesthesia?
YES
NO
Has
any
member
of
the
family,
including
your
child,
had
a problem
with
sedation
general
anesthesia?
ExplainExplain
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Explain
_______________________________________________________________________________________________
Are your
Are
child’s
your
child’s
immunizations
immunizations
up to date?
upup
toto
date?
YES
NO
Are your child’s immunizations
date?
YES
NO
Is thereIs any
there
other
any
health
other
health
information
information
that should
that
should
be
known?
bebe
known?
Is there
any
other
health
information
that
should
known?
ExplainExplain
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Explain
_______________________________________________________________________________________________
Dental History
Is this your child’s first dental visit?
❑ Yes
❑ No
Previous Dentist __________________________________________________________________________________________________
Date of Last Visit ____________________________Date of Last X-rays___________________________
How often does your child brush?________________________________________________________
Is tooth brushing supervised? ❑ Yes
❑ No
Is dental floss used?
❑ Yes
❑ No
Does your child receive (check all that apply):
_______Fluoride in vitamins
_______Bottled water
_______Fluoridated tap water
_______Fluoride tablets/drops
_______Well water
_______Non-fluoridated tap water
Any injuries to your child’s teeth or jaws? ❑ Yes
❑ No
Explain __________________________________________________________________________________________________
History of (check all that apply):
_______Currently Breastfeeding
_______Pacifier
_______Breastfed in past
_______Sippy cup
_______Thumb sucking
_______Bottle habits
_______Teeth grinding/clinching
Has your child experienced any unfavorable reaction from previous dental or medical care? ❑ Yes
❑ No
Explain __________________________________________________________________________________________________
How do you think your child will act toward the dentist?
________________________________________________________________________________________________________________
Has your child had recent dental pain or have a specific dental problem that needs special attention? ❑ Yes
❑ No
Explain __________________________________________________________________________________________________
Do you have questions for our staff prior to your child’s visit today?  Yes
 No
Consent
The permission of a parent or guardian is necessary for dental treatment of a minor.
As parent or guardian of the above patient, I authorize and request the performance of dental services for this patient by
Dr. Stark, Dr. Johnson, Dr. Egley, Dr. Garcia and their staff, as may be designated. I understand that Dr. Stark, Dr. Johnson, Dr.
Egley, Dr. Garcia and their staff will use digital radiographs (xrays), diagnostic, and patient management techniques that are
reasonable, necessary, and advisable. I have given an accurate report of this patient’s physical and mental health history.
I have also reported any prior allergic or unusual reactions to medications, latex, foods, or metals, and any other disease or
condition. I agree to inform Dr. Stark, Dr. Johnson, Dr. Egley, Dr. Garcia and their staff of any changes in the medical history. This
authorization is valid until revoked in writing.
Financial Authorization
Please indicate the manner you wish to handle your
account.
❑ I have no dental insurance. I will pay cash or check the day of
the appointment with a 5% courtesy discount.
❑ I have no dental insurance. I will pay with VISA, MasterCard,
Discover, Care Credit, or CitiHealth.
❑ I have dental insurance and will pay my estimated portion of the
total charges on the day of the appointment.
❑ I have Medicaid coverage.
I accept financial responsibility for this child. I
authorize the release of any dental information
necessary to process this claim and all future claims. I
authorize insurance payments directly to Lincoln
Pediatric Dentistry. I fully understand I am solely
responsible for any balance not paid by the
insurance company. I will be responsible for reporting
any changes in my child’s dental insurance
coverage. I will be responsible for any late fees due
on my account.
❑ I would like to discuss 3rd party financing through
Citi Health/Care Credit.
Signature ________________________________Relationship to child____________________________ Date___________________
2
Parent or Guardian Information
Name ________________________________________________________________________________________________ ❑ Male
❑ Female
First
MI
Last
Relationship to child
❑ Married ❑ Single ❑ Other
Birthdate_________________________________ SS#______________________________________
Address__________________________________________________________________________________________________________
City_______________________________________________________________________State________ Zip Code________________
Email__________________________________________________________________ Cell Phone_______________________________
Home Phone_______________________________ Work Phone_______________________________ Ext__________
Employer________________________________________________________Occupation_____________________________________
Name ________________________________________________________________________________________________ ❑ Male
❑ Female
First
MI
Last
Relationship to child
❑ Married ❑ Single ❑ Other
Birthdate_________________________________ SS#______________________________________
Address__________________________________________________________________________________________________________
City_______________________________________________________________________State________ Zip Code________________
Email__________________________________________________________________ Cell Phone_______________________________
Home Phone_______________________________ Work Phone_______________________________ Ext__________
Employer________________________________________________________Occupation_____________________________________
Emergency Contact Information (not parent/guardian)
Name____________________________________________________________Relationship to child ________________________
Address ______________________________________________________________________________________________________
Phone____________________________________
Primary Dental Insurance
Insured’s Name
________________________________________________________________________________________________
Insurance Company ____________________________________________________________________________________________
Insurance Phone
______________________________________________________________________________________________
Employer Name_____________________________________________ Employer Phone ____________________________________
Employer Address ________________________________________________________________________________________________
Secondary Dental Insurance
Insured’s Name
________________________________________________________________________________________________
Insurance Company ____________________________________________________________________________________________
Insurance Phone
______________________________________________________________________________________________
Employer Name_____________________________________________ Employer Phone ____________________________________
Employer Address ________________________________________________________________________________________________
Medicaid Insurance
Patient’s Name ___________________________________________________ I.D. # ________________________________________
Because referrals are important to us, who may we thank for referring you to our office?
__________Family __________Friend __________Doctor __________Dentist
Name ________________________________________________________________ Phone _________________________________
3
Heidi J. Stark, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Libby A. Johnson, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Emily J. Egley, D.D.S.
Diplomate, American Board of Pediatric Dentistry
Katie J. Garcia, D.D.S.
HIPAA Acknowledgement
Child
Parent or Guardian Name:
Birth
Patient’s Name:
City_
Relationship to Patient:
Child
As a parent or guardian of a patient of Lincoln Pediatric Dentistry,
I have received or have read and understand the information of said
dental office’s Notice of Privacy Practices.
Plea
Add
Hom
**You May Refuse to Sign This Acknowledgement**
Signature of parent, guardian or responsible person
Date:
For Office Use Only
We attempted to obtain written acknowledgement of our Notice of Privacy
Practices, but acknowledgement could not be obtained because:
o
o
o
o
Individual refused to sign
Communication barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Other (Please Specify)
North Office: 3272 Salt Creek Circle, Suite A • Lincoln, NE 68504 • 402-476-1500 • Fax 402-476-1510
Southeast Office: 4301 S. 80th St. • Lincoln, NE 68516 • 402-476-4301 • Fax 402-476-4305
www.lincolnpediatricdentistry.com
03/14