919-947-0800
300 S Center St Goldsboro, NC 27530
Patient Basic Information
Patient Name:
Preferred Name:
Birth Date:
Gender:
SSN:
Patient Contact Information
Address:
City:
State:
Zip Code:
Email:
Mobile Phone:
Patient Demographics
Employment Status:
Marital Status:
Language:
Ethnicity:
Race:
Primary Responsible Party Basic Information
Person Name:
Relationship:
Birth Date:
Gender:
SSN:
Primary Responsible Party Contact Info
Address:
City:
State:
Zip Code:
Email:
Mobile Phone:
Primary Responsible Party Insurance
Insurance Carrier:
Group #:
Subscriber #:
Start Date:
Additional Information
Emergency Contact Name:
Relationship:
Phone:
MEDICAL HISTORY
Is the patient under care by a physician?
Yes
No
Patient's Physician:
Address:
City:
State:
Zip Code:
Phone:
Date of last physical exam:
Date of last immunization:
Is the patient in good health?
Yes
No
Has there been any change in the patient’s general health within the past year?
Yes
No
Has the patient had a serious illness, operation, or been hospitalized within the past 5 years?
Yes
No
If yes, please list:
Is patient receiving any prescription or over-the-counter drugs?
Yes
No
If yes, please list medication and dosage:
Has your child ever been hospitalized?
Yes
No
Has your child ever had surgery:
Yes
No
Has your child ever had blood transfusions:
Yes
No
Medical Conditions
Autism:
Yes
No
Cerebral Palsy:
Yes
No
Asthma:
Yes
No
ADD/ADHD:
Yes
No
Down Syndrome:
Yes
No
Heart Murmur:
Yes
No
Heart Conditions:
Yes
No
Please list any other physical or psychological conditions not listed:
Allergies
Is your child allergic to, or has your child had a reaction to any of the following? To all ‘yes’ responses, specify the type of reaction.
Local anesthetics:
Yes
No
Reaction
Aspirin:
Yes
No
Reaction
Penicillin/Other antibiotics:
Yes
No
Reaction
Sulfa drugs:
Yes
No
Reaction
Codeine/Other narcotics:
Yes
No
Reaction
Metals:
Yes
No
Reaction
Latex:
Yes
No
Reaction
Iodine:
Yes
No
Reaction
Animals:
Yes
No
Reaction
Food:
Yes
No
Reaction
Dental History
Date of Last Dental Visit:
Any previous unhappy medical or dental visits?
Yes
No
If yes, please explain:
Has the patient complained about sensitivity or any dental problems?
Yes
No
Does the patient use floss?
Yes
No
Does the patient brush daily?
Yes
No
Does the patient receive any assistance with brushing?
Yes
No
Has the patient ever had orthodontic treatment (braces)?
Yes
No
Has the patient had any problems associated with previous dental treatment?
Yes
No
How does the patient receive fluoride (i.e.)?
Yes
No
Any injuries to the mouth, teeth or head?
Yes
No
If yes, please specify where and time of occurrence:
Is the patient currently experiencing dental pain or discomfort?
Yes
No
Does the patient grind their teeth?
Yes
No
Does the patient have sores or ulcers in their mouth?
Yes
No
Previous Physician and Acknowledgement
Has a physician or previous dentist recommended that the patient take antibiotics prior to dental treatment?
Yes
No
Does your child have any diseases, conditions, or problems not listed above that you think our practitioners should be aware of?
Yes
No
If yes, please list:
NOTE: Both, doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Patient/Patient’s Responsible Party Signature:
Print Name:
Date:
Consent
All children under 18 must be accompanied by a parent or legal guardian for their appointments. This includes new patient appointments (consults), six-month recall cleaning appointments, restorative appointments, and all orthodontic appointments. It is state law that a parent or legal guardian be present. If your child is brought by any other person they will be asked to reschedule. Further more, due to HIPPA regulations (confidentiality laws), we cannot discuss treatment with anyone other than a parent or legal guardian. Once patient turns 18 years of age we are no longer obligated to discuss treatment or account information with anyone but the patient.
I consent to the disclosure of patient records and or treatment information to the following persons who are involved in the patient's care or payment for that care.
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
My consent to disclosure of records shall be effective until I revoke it in writing.
Authorization and Release of Information
I agree that my dental insurance carrier may be billed for services provided and payment will be made directly to Goldsboro Pediatric Dentistry and Orthodontics. I also assume responsibility for any portion of the treatment cost not covered by my insurance carrier. I hereby give authorization for the release of any information requested or required by my insurance carrier with respect to any insurance claims.
I have read and understand the above.
Patient/Patient’s Responsible Party Signature:
Print Name:
Date:
GPDO: Media Consent
I consent that Goldsboro Pediatric Dentistry and Orthodontics may use photographs or videos of me, taken on the date indicated below, on their social media tools which includes, but not limited to their Facebook page. I understand that these images and/or videos will not be used for any other commercial purposes. Photographs may also be printed and placed for display at our office.
If person(s) in photos/videos is a minor, please list name(s) below:
Patient/Patient’s Responsible Party Signature:
Print Name:
Date: