All questions contained in this questionnaire are strictly confidential and will become part of the patient‛s record. We update our patient files every 6 months.

Patient’s Primary 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	INDIQUE CAMBIOS EN LAS SIGUIENTES ÁREAS (MARQUE TODO LO QUE APLIQUE):
MARITAL STATUS INSURANCE ADDRESS/PHONE/E-MAIL PRIMARY GUARDIANSHIP MEDICATIONS

	Patient’s Name:	Patient’s Name:	Patient’s Name:	Patient’s Name:
	Date of Birth:	Date of Birth:	Date of Birth:	Date of Birth:
Does the patient have any MEDICAL CONDITIONS? (For example: ADHD, Asthma, Autism, Cerebral Palsy,Diabetes, Epilepsy, Seasonal Allergies, etc)	Yes No	Yes No	Yes No	Yes No
If YES, what conditions?
Does the patient have any HEART conditions? (For example: Heart Murmur, Congenital Heart Defect, etc)	Yes No	Yes No	Yes No	Yes No
Does the patient require an ANTIBIOTIC before being seen?	¿Necesita el paciente ANTIBIÓTICO antes de ser visto?	Yes No	Yes No	Yes No	Yes No
If YES, did the patient take the antibiotic?	Si marco SÍ, ¿se tomó el paciente el antibiótico?	Yes No	Yes No	Yes No	Yes No
Does the patient have an ALLERGY to LATEX?	¿Es el paciente ALÉRGICO al LATEX?	Yes No	Yes No	Yes No	Yes No
Does the patient have any OTHER ALLERGIES? (For example: Animals, Foods, Medications, Nickel, etc)	¿Tiene el paciente ALGUNA ALERGIA? (Por ejemplo: Animales, Comidas, Medicamentos, Níquel, etc.)	Yes No	Yes No	Yes No	Yes No
If YES, what allergies?	Si marco SÍ, ¿qué alergias tiene?
Is the patient currently taking ANY medications/vitamins?	¿Toma el paciente ALGÚN medicamento/vitamina?	Yes No	Yes No	Yes No	Yes No
If YES, what medications/vitamins?	Si marco SÍ, ¿qué medicamentos/vitaminas toma?
Why is the patient taking this medication (i.e., what condition is it for)?	¿Por qué toma el paciente este medicamento (para qué condición)?
Do you (or the patient) have any DENTAL CONCERNS?	¿Tiene Ud. o el paciente alguna PREOCUPACIÓN DENTAL?	Yes No	Yes No	Yes No	Yes No
If YES, what concerns do you have?	Si marcó SÍ, ¿qué preocupación tiene?
CONSENT FOR TODAY
X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities	Radiografías (si es necesario): Esencial para diagnosticar caries y otras anormalidades	Yes No	Yes No	Yes No	Yes No
Fluoride Application: To help fight tooth decay and strengthen developing teeth	Aplicación de fluoruro: Para prevenir caries y fortalecer los dientes en su desarrollo	Yes No	Yes No	Yes No	Yes No

I certify 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 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 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 I may have made in the completion of this form. I affirm my signature represents my agreement to all the above-mentioned terms.


Signature	Firma	Date	Fecha