NEW PATIENT INFORMATION | Minor Child ABOUT YOU Patient Name:*(First)Middle Name(Middle)Last Name*(Last)I prefer to be called:Sex :Sex:MaleFemaleBirthday*Birthday Date Format: MM slash DD slash YYYY Address*City*State*Zip*Primary Phone:Social Security #:Email: School:Grade: PARENT/GUARDIAN INFORMATION Father'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):AddressCityStateZipSignature:Date: 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: Date Format: MM slash DD slash YYYY Name of Insurance CompanyInsurance 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 BY Name of Referral:Relationship of Referral:Or Referral By: Phone Book Newspaper Radio Website Facebook Other DENTAL HEALTH INFORMATION When 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)12345678910 MEDICAL INFORMATION Name 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 allergiesOther allergies:Have you been told that he/she requires antibiotic pre-medication prior to dental treatment?YesNoWhy?PregnantYesNoNursingYesNoTaking birth control pillsYesNoHas 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 QUESTIONNAIRE 1. Does your child snore or breathe heavily at night?YesNoHow 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 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)Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.