100 E. Kings Fort Pkwy Suite 100
Kaufman, TX 75142
Office: 972-932-3918 Fax: 972-932-3728
Thank you for visiting Texas Dentistry. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Patient Information
Legal Name: LAST ______FIRST ______MIDDLE______
Preferred Name: ______Mother’s Maiden Name: ______Sex: □ Male □Female
DOB: _____/______/_____ Social Security #:_____-_____-______Language Preferred: □ English □ Spanish □ other: ______
Address: ______City/State/ Zip: ______
Cell Phone: ______Alternate Phone: ______Home Phone: ______
Email: ______Would you like to be updated by text messaging? __Yes __No
May we know how you heard about our office? ______
Responsible Party Information
Are parents married? Yes No If no, which parent does patient usually live with? ______
Mother’s Name or Legal Guardian: ______D.O.B ____/____/____ Relation to Patient: ______
SS# ______Address: ______City/State/ Zip: ______Cell Phone: ______Home Phone: ______Alternate Phone: ______
Employer Name: ______Address: ______City/State/Zip: ______
Father’s Name or Legal Guardian: ______D.O.B ____/____/____ Relation to Patient: ______
SS# ______Address: ______City/State/ Zip: ______Cell Phone: ______Home Phone: ______Alternate Phone: ______
Employer Name: ______Address: ______City/State/Zip: ______
Emergency Contact Information (Not in same household)
Name: ______Relationship to Patient:______Contact Phone Number:______
Consent for Minor
Patients Name: ______
Are you the:
· Parent (please write your name and your spouse’s name) ______
· Legal Guardian (please write your name) ______
· Other (please write your name and explain why) ______
If we can not reach you about the changes in the child's treatment, are there others that you would allow to give consent in your absence? (must be over 18) If YES, please give the names and relationship to the patient. Yes, ______
Please list anyone that you would not allow to consent in your absence. ______
Signature: ______Date/Time: ______
100 E. Kings Fort Pkwy Suite 100
Kaufman, TX 75142
Office: 972-932-3918 Fax: 972-932-3728
Insurance Information
Primary Insurance: ______Eligibility/Benefits Ph #:______SS#/Policy #: ______
Subscriber/Cardholder: ______DOB:______Address:______
Secondary Insurance: ______Eligibility/Benefits Ph #:______SS#/Policy #: ______
Subscriber/Cardholder: ______DOB:______Address:______
Physician Information
Primary Care Physician Name: ______Phone #: ______
Address: ______City/State/ Zip: ______Fax Phone: ______
Specialty Physician Name: ______Phone #: ______
Address: ______City/State/ Zip: ______Fax Phone: ______
Insurance Authorization Statement (Sign & Date)
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I also understand that it is my responsibility to give accurate insurance information to the best of my knowledge. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history is correct to the best of my knowledge.
Signature: ______Date/Time: ______
Consent/Consentimiento
Do you give consent for dental x-rays to be taken? Da usted su consentimiento para radiografias dentales se deben tomar
□No □Yes If No, Reason?______□No □Si Si No, La Razon?______Do you give consent for prophylaxis cleaning to be performed? Usted da consentimiento para proceder con la limpieza?
□No □Yes If No, Reason?______□No □Si Si No, La Razon?______
Is the patient being seen today currently pregnant? El paciente que sera visto hoy esta embarazada? □No □Yes If Yes, How many months?______□No □Si En caso afirmativo, Cuantos meses?______
I GRANT/DO NOT GRANT permission for my photo/image, without any other personal identifiers, to be published on the Texas Dentistry for Kids Facebook/Instagram or any affiliated website.
Yo CONCEDO/ NO CONCEDO permiso para mi foto / imagen que no incluya ningún otro identificador personal, que se publicara en la pagina de internet de Texas Dentistry For Kids
Signature: ______Date/Time: ______
100 E. Kings Fort Pkwy Suite 100
Kaufman, TX 75142
Office: 972-932-3918 Fax: 972-932-3728
Source of Information Fuente de Informacion
Primary Care Physician; ______Medico de cabecera:______
Referring Physician/Clinic:______Medico que lo remiti/Clinica:______
Diagnosis:______Diagnostico:______
Person Providing Information:______Person que suministra la informacion:______
Relationship to Patient:______Relacion con el paciente:______
Language Spoken:______Idioma que habla:______
Chief Complaint Motivo principal de la consulta
Reason for today’s visit:______Motivo de la consulta:______
______
What would you like to talk about or have happen today? De que desea hablar o que necesita hoy?______
______
Past History Antecedentes
Are immunizations UP TO DATE? □No □Yes Estan sus vacunas AL DIA? □No □Si
Is the patient allergic to any medications? □No □Yes Es el paciente alergico a algun medicamento? □No □Si
If yes, please list:______Si la repuesta es si, por favor indique a cuales:______
Please list reactions:______Por favor, especifique la reaccion:______
Is the patient allergic to LATEX? □No □Yes Es el paciente alergico al LATEX? □No □Si
Is the patient taking prescribed medications? □No □Yes Toma el paciente medicamentos recetados? □No □Si
Medications Dose Times Per Day Medicamentos Dosis Cuantas veces al dia
______
______
______
______
What was the patient’s birth weight? ____pounds __ounces Cual fue el peso del paciente al nacer? ____libras ____onzas
Was the patient premature? □No □Yes Tuvo el paciente un nacimiento prematuro? □No □Si
Did the patient have breathing problems? □No □Yes Ha padecido el paciente problemas respiratorios?□No □Si
Did the patient have jaundice? □No □Yes Ha tenido el paciente icteria (color amarillento)? □No □Si
Did the patient have blood transfusions? □No □Yes Se le han hecho al paciente transfusiones de sangre? □No □Si
Did the patient stay in the newborn ICU? □No □Yes Estuvo el paciente en terapia intensiva (ICU) al nacer? □No □Si
Did the patient have complications during birth? □No □Yes Presento el paciente complicaciones durante el nacimiento?
If yes, please explain:______Si la repuesta es si, por favor explique:______
______
Has the patient ever been hospitalized? □No □Yes Ha sido el paciente alguna vez hospitalizado?
If yes, please list reason/when:______Si la repuesta es si, por favor indique el motive y cuando
______ocurrio:______
Has the patient had any operations? □No □Yes Se ha sometido al paciente a alguna operación?
If yes, please list what/when:______Si la repuesta es si, por favor indique que tipo y cuando
______ocurrio:______
100 E. Kings Fort Pkwy Suite 100
Kaufman, TX 75142
Office: 972-932-3918 Fax: 972-932-3728
Has the patient had any serious illnesses of the following? Ha padecido el paciente alguna de las siguientes enfermedades?
Asthma □No □Yes Asma □No □Si
Sleep Apnea □No □Yes Apnea del sueño □No □Si
Seasonal/Environmental Allergies □No □Yes Alergias de temporada/ ambienales □No □Si
Autoimmune Disorders □No □Yes Trastornos autoinmunitarios □No □Si
Bleeding Disorders □No □Yes Trastornos hemorragicos □No □Si
Births Defects □No □Yes Defectos congenitos □No □Si
Brain Damage or Neurologic Problems □No □Yes Dano cerebral o problemas neurologicas □No □Si
Developmental Problems □No □Yes Problemas de desarrollo □No □Si
Diabetes □No □Yes Diabetes □No □Si
Hypoglycemia-Low Blood Sugar □No □Yes Hipoglucemia □No □Si
Heart Disease or Heart Murmur □No □Yes Enfermedad o soplo cardiaco □No □Si
Rheumatic Fever □No □Yes Fiebre reumatica □No □Si
Seizures or Convulsions □No □Yes Convulsiones o epilepsia □No □Si
Sickle cell Disease or Trait □No □Yes Anemia drepanocitica o rasgo □No □Si
Cancer/ Malignant Tumor □No □Yes Cancer/ Tumor malign □No □Si
Radiation? □No □Yes Radiacion? □No □Si
Chemotherapy? □No □Yes Quimioterapia? □No □Si
Has the patient had any or ever been exposed to the following: Ha padecido el paciente o alguna vez ha estado expuesto a alguno de los siguientes?
Hepatitis □Had □Exposed to Date______Hepatitis □Had □Exposed to Date______
Herpes □Had □Exposed to Date______Herpes □Had □Exposed to Date______
HIV/AIDS □Had □Exposed to Date______VIH/sida □Had □Exposed to Date______
Scarlet Fever □Had □Exposed to Date______Escarlatina □Had □Exposed to Date______
Review of Systems Examen de los sistemas corporals
Has the patient had any of the following problems? If yes Ha presentado el paciente alguno de los siguientes problemas? Please describe Si la respuesta es si, por favor especifique :
Dizziness / Fainting Spells □No □Yes ______Mareos / Desmayos □No □Si ______
Eye Problems □No □Yes ______Problemas de la vista □No □Si ______
Headaches □No □Yes ______Dolores de cabeza □No □Si ______
Ear infections □No □Yes ______Infecciones de oido (otitis) □No □Si ______
Nose Bleeds □No □Yes ______Hemorragia nasal □No □Si ______
Sleep Apnea □No □Yes ______Apnea del sueno □No □Si ______
Sore Throat □No □Yes ______Dolor de garganta □No □Si ______
Runny Nose □No □Yes ______Nariz aguada □No □Si ______
Breathing Problems □No □Yes ______Problemas respiratorios □No □Si ______
Pneumonia □No □Yes ______Neumonia □No □Si ______
Teeth/ Sore Gums □No □Yes ______Dolor de dientes o encias □No □Si ______
Stomach Problems □No □Yes ______Problemas estomacales □No □Si ______
Kidney /Bladder Problems □No □Yes ______Problemas renales o de vejiga □No □Si ______
Sore Joints □No □Yes ______Articulaciones adoloridas □No □Si ______
Muscle Weakness □No □Yes ______Debilidad muscular □No □Si ______
Genetic Disorders □No □Yes ______Trastornos geneticos □No □Si ______
Endocrine /Hormone Problems □No □Yes ______Problemas endocrinos u hormonales □No □Si ______
100 E. Kings Fort Pkwy Suite 100
Kaufman, TX 75142
Office: 972-932-3918 Fax: 972-932-3728
Family History Antecedentes famillares
Do any family members have any medical problems? If yes, Alguno de sus familiars tiene algun problema medico? Si la
Please list which family member respuesta es si, por favor indique que familiar.
Bleeding Disorder □No □Yes ______Trastornos hemorragicos □No □Si ______
Asthma □No □Yes ______Asma □No □Si ______
Birth Defects □No □Yes ______Defectos congenitos □No □Si ______
Diabetes □No □Yes ______Diabetes □No □Si ______
Hypoglycemia □No □Yes ______Hipoglucemia □No □Si ______
Neuromuscular Problems □No □Yes ______Problemas neuromusculares □No □Si ______
Sickle Cell Disease □No □Yes ______Anemia drepanocitica □No □Si ______
Seizures or Convulsions □No □Yes ______Convulsiones o epolepsia □No □Si ______
Trouble with Anesthesia □No □Yes ______Problemas con la anestesia □No □Si ______
Malignant Hyperthermia □No □Yes ______Hipertermia maligna □No □Si ______
Additional Information:
______
Signatures Firmas
Assistant Name:______Nombre del Asistente: ______
Assistant Signature:______Firma del Asistente: ______
Date:______Time:______Fecha: ______Hora: ______
Parent/Legal Guardian Signature:______Firma del padre o tutor lega: ______
Date:______Time:______Fecha: ______Hora: ______
I have reviewed the above information. He revisado la informacion que precede.
Dr. Signature:______Firma del medico:______
Date:______Time:______Fecha:______Hora: ______
Texas Dentistry for Kids and Oral Health Industries, LLC complies with applicable Federal civil rights law and does not discriminate on the basis race, color, national origin, age, disability, or sex.
Notice of Privacy Act
This notice describes how medical and dental information about you and/or your child may be used and disclosed and how you can get access to this information. Please review it carefully.
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
1. To other health care providers (i.e., your/or your child’s oral surgeon,ect.) in connection with our dental treatment to you or your child.
2. To third party payers or spouses (ie., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, ect.) in order to obtain payment of your account (ie., to determine benefits, dates of payment, ect)
3. To certifying, licensing and accrediting bodies (ie., the American Board of Dentist, state dental boards, ect.) in connection with obtaining certification, licensure or accreditation.
4. Internally, to all staff members who have any role in your/or your child’s treatment; and or,
5. To other patients and third parties who may see or over hear incidental disclosures about your/ or your child’s treatment, scheduling ect:
6. To your family and close friends involved in your/ or your child’s treatment;
7. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you;
And other uses or disclosures of you, or your child’s protected health information will be made only after obtaining your written authorization, which you have the right to revoke.
1. Request restrictions on the use and disclosure of your/ or your child’s protected health information;
2. Request confidential communication of your, or your child’s protected health information;
3. Inspect and obtain copies of your, or your child’s protected health information through asking us;
4. Amend or modify your, or your child’s protected health information in certain circumstances;
5. Receive an accounting of certain disclosures made by us of your, or your protected health information; and,
6. You may, without risk of retaliation, file a complaint regarding a dental professional, by e-mailing the SBDE Enforcement Division at or by phone @1.800.821.3205 (which must be filed within 180 days of the violation)
We have the following duties under the privacy rules:
1. By law, to maintain the privacy of, protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
2. To abide by the terms of our Privacy Notice that is currently In effect;
3. To advise you of right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
1. Honor any request by you to restrict the use of disclosure of your protected health information:
2. Amend your protected health information if, for example, it is accurate and complete, or,
3. Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information on this Notice, please ask for our Privacy Person or direct your questions to this person at our office address. Thank you.
PATIENT ACKNOWLEDGEMENT
I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice
______
Patient/Responsible Party Date