Welcome Back!

Please complete the following questions. We update our patient files every 6 months.
   
Patient’s Name: Date of Birth:
Address: City: State: Zip:
Who does the patient live with?:      Both Parents       Mother      Father      Other: 
Parent’s/Guardian’s Name:
Home Number: Cell/Mobile Number:
Which number would you like to have appointments confirmed?   HOME     CELL/MOBILE
E-mail Address:
INDICATE CHANGES TO THE FOLLOWING (CHECK ALL THAT APPLY):If insurance has changed, please provide a copy of the new insurance card
  MARITAL STATUS       INSURANCE       ADDRESS/PHONE/E-MAIL       PRIMARY GUARDIANSHIP       MEDICATIONS
 

 CONDITIONS

Does the patient have any MEDICAL CONDITIONS?
(For example: ADHD, Asthma, Autism, Cerebral Palsy,Diabetes, Epilepsy,
Seasonal Allergies, etc)		   Yes     No
If YES, what conditions?  
Does the patient have any HEART conditions?
(For example: Heart Murmur, Congenital Heart Defect, etc)		   Yes     No
If YES, what conditions? 

 ALLERGIES

Does the patient have an ALLERGY to LATEX?   Yes     No
Does the patient have any OTHER ALLERGIES?
(For example: Animals, Foods, Medications, Nickel, etc)		   Yes     No
If YES, what allergies? 

 MEDICATIONS

Is the patient currently taking ANY medications/vitamins?   Yes     No
If YES, what medications/vitamins?  
Why is the patient taking this medication (i.e., what condition is it for)?  

 DENTAL CONCERNS

Do you (or the patient) have any DENTAL CONCERNS?   Yes     No
If YES, what concerns do you have?  

 CONSENT FOR TODAY

X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities   Yes     No
Fluoride Application: To help fight tooth decay and strengthen developing teeth   Yes     No
 

I certify that the information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the patient’s medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I authorize the release of all information necessary to secure benefits otherwise payable to me. I assign directly Growing Smiles Pediatric Dentistry, PC all insurance payments otherwise payable to me. I understand that I am responsible for the full balance of the account regardless of my dental benefits. 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 acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the dentist or any member of the staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I affirm that my signature represents my agreement to all the above-mentioned terms.

 

Signature