PhD DENTAL

Date: Patient Name: tsaL etneicaP led erbmoN :ahceF (Apellido) First (Nombre) Middle (Inicial)

Address: ( edoC piZ )odatsE( etatS )daduiC( ytiC )ellaC( teertS noiceriD Codigo Postal)

Home Phone ( ) Cell Phone ( ) Social Security # Driver’s License #

naM ed saisneciL ed laicoS orugeS ed # raluleC asaC ed onofeleT ejas Birthdate If Patient is a minor, Give parents/Guardians Name Fecha de Nacimiento Si el paciente es menor de edad, ponga el nombre de padre o tutores Emergency Contact Name Telephone: En caso de Emergencia con queien onofeleT sonracinumoc soamedop How were you referred to our office Email Address: como fue referido a nuestra officina

Name: Marital Status: Nombre Estado Civil Mailing Address:

anoZ(piZ )odatsE( etatS )daduiC( ytiC )ellaC( teertS noicerriD Postal) Social Security # Birthdate Insured’s Name

odarugsA ed erbmoN otneimicaN ed ahceF laicoS orugeS eD #Employer Insurance Company Social Security #

# asnarugesA ed ainapmoC rodaelpmE de Seguro Social del Asgurado Employer’s Address Telephone ( )

onofeleT rodaelpme us ed noicceriD

Date of last dental examination (Cuando fue su ultimo examen dental):

How would you describe your current dental problem: En este momento, como podria describer su problema dental?

I understand the information below is necessary to provide me with dental care in a safe efficient manner. I have answered all questions truthfully and to the best of my knowledge. Yo entiendo que la informacion anterior es para darme tratamiento dental en una forma eficiente y segura. Me contestado todas las preguntas de acuerdo a mi conocimiento.

1. Are you having pain or discomfort at this time? Yes/Si □ No □

esta sintiendo dolor o molestia en este momento

2. Have you been a patient in a hospital during the past two years? □ oN □ iS/seY ha sido hospitalizado durante los ultimos dos anos

3. Have you been under the care of a medical doctor the past two years? □ oN □ iS/seY A estado bajo atencion medica con un doctor durante los ultimos dos anos

4. Are you now taking any medication or drugs? Yes/Si □ No □

Esta usted presentamente tomando alguna medician o droga? Please list any current medications you are taking por favor indique cual medicamenta que esta tomando actualmente

5. Did you take any medications in the past:? Yes/Si □ No □ Ha usted tomado medicamente en el pasado? Please list any medications you took ( ex. phen-fen) Por favor indique cualquier medicamento que tomo en el pasado (ex phen-fen):

6. Are you sensitive or allergic to any medication or anesthetics? □ oN □ iS/seY Es usted alergico a algun medicamento o a la anestesia? If yes, Please list (Si contesto si, por favor indique):

7. Indicate which of the following you had or have at present (Circle Yes or No): Indique cual de los sintomas ha tenido o tiene presentemente (Circule “Si o No” tal como corresponde)

Responsible Party Information (Informacion de la Persona Responsable)

Health History & Patient Information ( Informacion Sobre Paciente)

Dental Information (Informacion Dental)

Medical Information (Condicion Medica)

/ Y amhtsA / amhtsA N / Y senoniR ed samelborP / elbuorT yendiK N Cold Sores / Ampoyas o Fiebre Y / N

B N / Y xetal ed aigrelA / ygrellA xetaL N / Y oilobmE / ekortS lood Transfusion / Transfusion de Sangre Y / N

noR y saigrelA / seviH & seigrellA N / Y omsitameR / msitamuehR chas Y / N Liver Disease / Enfermedad del Higado Y / N

tisuniS ed samelborP / elbuorT suniS N / Y sitirtrA / sitirhtrA N / Y siliV / ecidnuaJ wolleY N / Y si

Rheumatic Fever / Fiebre Reumatico Y / N Radiation Therapy / Terapia de Radiacion Y / N Epilepsy or Seizures / Ataques o Epilepsia Y / N

High Blood Pressure / Alta Presion Y / N Hepatitis A/BC /Hepati N / Y omsisoivreN / ssensuovreN N / Y C/B/A sit

Heart Disease or Attack/ Ataque de corazon o problem Y / N Venereal Disease / Enfermedades Venereas Y / N Developmentally Disabled / Mentalmente Dis. Y / N

Heart Murmur / Soplo del Corazon Y / N Tuberculosis / Tuberculo N / Y ADIS / sdiA N / Y sis

Angina Pectoris / Angina de Pec / Y sitebaiD / setebaiD N / Y oh N / Y + VIH / + VIH N

8. Do you have/had any diseases, condition, or problem not listed? Ha tenido o tiene enfermedad, condicion o problema quo no fue indicado? If yes, Please list ( Si constesto si, por favor indique):

1. I understand that all responsibility for payment for dental services provided in this office for myself or my dependent(s) is mine due and payable at the time services are rendered. Entiendo que toda la respnsabilidad para el pago de servicos dentales proporcionados en esta oficina para mi o mis dependientes es mia. los servicios seran debidos y pagados en el tiempo que han sido rendimos a menos que otros arreglos se hayan hecho. Si los pagos del acontecimiento no son receridos para las fechas acordadas, entiendo que tal ves un cargo de (18% apr de finanzas) seran anadido a mi cuenta. ademas de cualquier cargas de la coleccion. 2. I understand that where appropriate, credit bureau reports may be obtained. Entiendo qu donde sea apropiado, un reporte de credito de la oficina de reportes de credito quisas sea obtenido. 3. I understand that it is my responsibility to advise your office of any changes in the information contained on this form. Entiendo que es mi responsabilidad de avisar a su oficina de cualquier cambio en la informacion contenida en esta forma.

Parent or responsible party: Relationship to patient: etneicaP la noicaleR elbisnopser anosrep a erdaP

Notice to patient: We are required to provide you with a copy of our notice of privacy practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the notice. You may refuse to sign this acknowledgment, if you wish. I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.

Please print your name here: Signature: Date:

Acknowledgement of receipt of notice of privacy practices

Doctor Signature: Date:

For Women Only (Para la Mujer Solamente)

Are you pregnant: Yes / No Esta embarazada? Si / No Are you taking birth control pills? Yes / No

What Month: Que Mes:

Are you nursing: Yes / No Esta amamantando: Si / No

Esta tomando pastillas anti-conceptivas Si / No

Consent (Consentimiento)

For office use only We have made every effort to obtain written acknowledgment of receipt of our notice of privacy from this patient but it could not be obtained because: The patient refused to sign Due to an emergency situation it was not possible to obtain acknowledgment We weren’t able to communicate with the patient: Other(please provide specific details):

Employee signature: Date:

HIPPA Acknowledgement of receipt of the Notice of Privacy Practices. This form does not constitute legal advice and covers only federal, not state law.