NEW PATIENT INFORMATION | Minor ChildABOUT YOUPatient Name:* (First)Middle Name (Middle)Last Name* (Last)I prefer to be called: Sex :Sex: Male Female Birthday*Birthday MM slash DD slash YYYY Address* City* State* Zip* Primary Phone:Social Security #: Email: School: Grade: PARENT/GUARDIAN INFORMATIONFather's Name: Father's SSN#: Father's Employer: Work #:Cell #:Mother's Name: Mother's SSN#: Mother's Employer: Work #:Cell #:Party Responsible for Payment (Full Name): Address City State Zip Signature: Date: MM slash DD slash YYYY DENTAL INSURANCEWe will gladly assist you in filing the claims for your primary insurance if provided with the necessary information and a copy of the insurance card.Mark for no dental insurance Mark for no dental insurance Full name of the Policy Holder Policy Holder SS#: Policy Employer: Policy Holder Birthday: MM slash DD slash YYYY Name of Insurance Company Insurance Group #: Member ID#: I understand that payment is expected on the day of each service. I realize I am also responsible for any remaining charges that my insurance company chooses not to pay.REFERRED BYName of Referral: Relationship of Referral: Or Referral By: Phone Book Newspaper Radio Website Facebook Other DENTAL HEALTH INFORMATIONWhen was his/her last dental visit? Name of previous dentist: Does he/she have any current dental issues or concerns you would like to discuss or addressWhat (if anything) would he/she like to change about the appearance of their smile? Does he/she have any fears about visiting the dentist (pain, cost, previous bad experience, lack of time, etc.)? On a scale of 1 to 10 how would you rate his/her dental health? (1 being poor, 10 being excellent) 1 2 3 4 5 6 7 8 9 10 MEDICAL INFORMATIONName of Primary Physician: Date of last visit: Any recent illness/doctor care or surgeries, please list:List all medications he/she is currently taking:All medical allergies Other allergies: Have you been told that he/she requires antibiotic pre-medication prior to dental treatment? Yes No Why? Pregnant Yes No Nursing Yes No Taking birth control pills Yes No Has he/she ever been treated for or experienced any of the following? (Please check all that apply.) Sleep Disorder/Apnea CPAP Therapy/Machine Daytime Sleepiness Acid Reflux Clenching/Grinding of Teeth Does he/she have a history of any of the following? (Please check all that apply.) AIDS Cortisone Treatments HIV Positive Respiratory Disease Anemia Diabetes Jaw Pain Rheumatic Fever Arthritis Epilepsy Kidney Disease Scarlet Fever Artificial Heart Valve Fainting Latex Allergy Seizures Artificial Joints Glaucoma Liver Disease Shortness of Breath Asthma Headaches Mitral Valve Prolapse Stroke Back Problems Heart Murmur Nervous Problems Swelling of Feet/Ankles Blood Thinners Heart Problems Pacemaker Thyroid Problem Cancer Phen-fen or Diet Pills Tobacco Habit Chemical Dependency Hemophilia Prolonged Bleeding Tuberculosis Chemotherapy Hepatitis Psychiatric Care Ulcer Circulatory Problem High Blood Pressure Radiation Treatment Venereal Disease Describe Your Heart Problem: Other: PEDIATRIC QUESTIONNAIRE1. Does your child snore or breathe heavily at night? Yes No How often and how loud? 2. Do you notice your child breathing through their mouth? 3. Does your child grind his or her teeth? 4. Does your child move around or are they restless when they sleep? 5. Does your child seem hyperactive or have they been diagnosed with ADHD? 6. Does your child have any history of habits such as pacifier or thumb sucking, lip biting, etc? 7. Does your child have allergy issues or frequent sore throat/ear infections? 8. Does your child have any issues wetting the bed? HIPAA FORM I HAVE BEEN OFFERED AND/OR RECEIVED A COPY OF GROVE DENTAL ASSOCIATES’ NOTICE OF PRIVACY PRACTICESI UNDERSTAND THAT MY PHI (PROTECTED HEALTH INFORMATION) CAN AND WILL BE USED FOR PURPOSES OF TREATMENT AND FOR PAYMENT FROM BOTH MYSELF AND/OR THIRD PARTY. I UNDERSTAND THAT I MAY REQUEST A COPY OF THE PRIVACY POLICIES AT ANY TIME.I UNDERSTAND I MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENTI GIVE CONSENT FOR THE OFFICE OF GROVE DENTAL ASSOCIATES TO SHARE PERSONAL INFORMATION REGARDING APPOINTMENTS, TREATMENT, BALANCE, ETC, WITH THE FOLLOWING FAMILY MEMBERS / SPOUSE/FRIENDS/OTHER. PLEASE LIST NAME / RELATIONSHIP AND SIGN BELOW OR PLEASE WRITE NO ONE IF YOU DO NOT WANT YOUR INFORMATION SHARED WITH ANYONE,1. Name / Relationship 2. Name / Relationship 3. Name / Relationship PRINT PATIENT NAME PRINT PATIENT NAMEPATIENT SIGNATURE OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18) PATIENT SIGNATURE OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)Date MM slash DD slash YYYY CAPTCHA Δ