Welcome to Chico Pediatric Dentistry!

Drs. Roos and Tornabene, DDS | 2775 Esplanade • Chico,CA 95973
  • Last Name
  • First Name
  • Middle Name
  • Preferred Name
  • Address 1
  • Address 2
  • City
  • State
  • Zip Code
  • Home
  • Mobile
  • Work
  • Ext
  • Emergency Name
  • Emergency Phone
  • Emergency Contact Name
  • Emergency Phone
  • Emergency Name
  • Emergency Contact Phone
  • Last Name
  • First Name
  • Middle Name

Medical History

Indicate which of the following you have had or have at present. By checking the box it will indicate a "Yes" response. leaving blank will indicate a "No" response.

HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

Acknowledgement of Receipt of Dental Materials Fact Sheet

Patient health and the safety of dental treatments are the primary goals of our dental practice. The purpose of this fact sheet is to provide you with information concerning the risks and benefits of all dental materials used in the restorations (fillings) of the teeth.

We are required by law to make this dental materials fact sheet available to every pateint of record in our office. This fact sheet is avaialble upon request.

As the parent/guardian, you have the right to discuss with your dentist the facts presented concerning the filling materials being considered for your childs treatment.

I acknowledge that I have been given the option to request a copy of this office's Dental Materials Fact sheet dated May 2004.

Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.