NEW PATIENT INFORMATION ABOUT YOU Patient Name:*(First)Middle Name(Middle)Last Name*(Last)Name PrefixMr.Mrs.Ms.Dr.I prefer to be called:Sex :Sex:MaleFemaleBirthday*Birthday Date Format: MM slash DD slash YYYY Address*City*State*Zip*Home Phone:Work:Cell:Social Security #:Email: Employer:Occupation:Emergency Contact:Emergency Phone #: SPOUSE INFORMATION No spouse information No spouse information Spouse's NameSpouse's Employer:Primary Phone #:Birthday: Date Format: MM slash DD slash YYYY DENTAL INSURANCE We 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 HolderPolicy Holder SS#:Policy Employer:Policy Holder Birthday:Relationship to Policy Holder:Name of Insurance CompanyInsurance Group #:Member ID#:Signature:Date: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 BY Name of Referral:Relationship of Referral:Referral By: Phone Book Newspaper Radio Website Facebook Other DENTAL HEALTH INFORMATION When was your last dental visit?Name of previous dentist:Do you have any current dental issues or concerns you would like to discuss or addressWhat (if anything) would you like to change about the appearance of your smile?Do you 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 your dental health? (1 being poor, 10 being excellent)12345678910 MEDICAL INFORMATION Name of Primary Physician:Date of last visit:Any recent illness/doctor care or surgeries, please list:List all medications you are currently taking:Are you currently or have you ever taken any medication or bisphosphonates for osteoporosis?YesNoAll medical allergiesOther allergies:Have you been told that you require antibiotic pre-medication prior to dental treatment?YesNoWhy?PregnantYesNoNursingYesNoTaking birth control pillsYesNoHave you 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 Do you 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: HIPAA FORM I HAVE BEEN OFFERED AND/OR RECEIVED A COPY OF GROVE DENTAL ASSOCIATES’ NOTICE OF PRIVACY PRACTICES I 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 ACKNOWLEDGEMENT I 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 / Relationship2. Name / Relationship3. Name / RelationshipPRINT PATIENT NAMEPRINT 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)DateDate This iframe contains the logic required to handle Ajax powered Gravity Forms.