Services

New patient forms

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X-Ray radiographs refusal form

Fishman Pediatric Dentistry 552 Jacksonville Dr. Jacksonville Beach, FL 32250 (904)247-4097 This form is so that I may fully understand what is recommended for my child and the risks associated with refusing dental radiographs (x-rays). The American Dental Association’s and the Food and Drug Administration’s current guidelines prescribing dental radiographs (x-rays) are as follows: Routine [...]

X-Ray and Fluoride Consent

X-Ray Consent It is recommended that children have check-up (bitewing) x-rays at each 6 months recall appointment. This is required so that the doctor is able to diagnose any new decay in your child’s mouth since their last visit. The policy holder is responsible for outstanding balance if insurance does not cover additional set of [...]

Records Release

Ross Fishman, DMD, MS Board Certified in Pediatric Dentistry Practice Limited to Children and Teens Records Release Form I hereby authorize Fishman Pediatric Dentistry to release all dental radiographs for: Patient Name* First Last DOB* Date Format: MM slash DD slash YYYY Patient Name First Last DOB Date Format: MM slash DD slash YYYY Patient [...]

Post Appointment Survey

Please describe your overall experience.Please describe your experience with the doctor and staff.What was your favorite thing about your visit?What areas could we improve upon to make your experience more enjoyable?Would you like a member of our team to contact you to further discuss your experience?YesNoName First Last Email

Patient Screening Form: Pre-Appointment

Patient Name* First Last Date* Date Format: MM slash DD slash YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YesNoAre you/they having shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you/they experienced recent loss of taste [...]

Patient Screening Form: In-Office

Patient Name* First Last Date* Date Format: MM slash DD slash YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YesNoAre you/they having shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you/they experienced recent loss of taste [...]

Notice of Privacy Policy

Fishman Pediatric Dentistry As a patient at this office, the doctor and assistants will obtain information about you and record it in a health record with your consent. The practice is permitted by Federal Privacy Laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected [...]

New Patient Information

Date* Date Format: MM slash DD slash YYYY Patient Name* First Last NicknameWeightIn poundsHeightIn inchesSexDOB* Date Format: MM slash DD slash YYYY AgePlease enter a number less than or equal to 99.Patient Name First Last NicknameWeightIn poundsHeightIn inchesSexDOB Date Format: MM slash DD slash YYYY AgePlease enter a number less than or equal to 99.Patient [...]

Medical History Form

Fishman Pediatric Dentistry / 552 Jacksonville Dr. / Jacksonville Beach Fl, 32250Child's Name* First Last Date* Date Format: MM slash DD slash YYYY Is your child under the care of another physician/specialist?YesNoName of other physician/specialist:Reason for seeing other physician/specialist:Is your child receiving any medication?*YesNoList medication(s):Does your child have any allergies, such as PENICILLIN / LATEX?*YesNoList [...]