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Dental Land Patient Registration and History Form PATIENT INFORMATION Patient Name:______________________________________________________________________ Age:__________________ DOB:__________________ Nombre de Paciente Edad Fecha de Nacimiento Sex Male/Female SS#_______________________________ Address:_____________________________________________________________________ Sexo masculino/femenino Dirección City:_____________________________________________________________ State________________________ Zip____________________ Ciudad Estado Código Postal PH:_________________________________________________ Mobile:______________________________________________ Teléfono Numero de Celular Emergency Contact Name:_____________________________________________________ PH:_____________________________________ En caso de emergencia Telephono Relationship to patient:________________________________________________________ Relación INSURANCE INFORMATION Do you have any Dental Insurance Yes No Medicaid Yes No Chip Yes No Tienes algún seguro Dental Name:__________________________________________________________ Address:____________________________________________________________ Nombre Dirección Subscriber Name:___________________________________________________ DOB:_______________SS#_________________________ Nombre de suscritor ID:____________________________ Group#__________________________ Employer:______________________________________________________ Nombre de Empleado Is the patient the subscriber Yes No Other:________________________________________________________________ El paciente el suscriptor Si No Otro ASSIGNMENT AND RELEASE I certify that I and/or my dependent(s) have insurance coverage with____________________________________ and assign directly to Dr. __________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-­names dentist may use my health care information and may disclose such information to the above-­names Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. ______________________________________________________________________________________________________________________________________________________ Signature of Patient, Parent, Guardian, or Personal Representative Date ______________________________________________________________________________________________________________________________________________________ Please Print name of Patient, Parent, Guardian, or Personal Representative Date DENTAL HISTORY Reason for today’s _____________________________________________________________________________________________________________________ Razon de su visita Mark Yes or No to the following questions: (Marque sí o No a las siguientes preguntas) Bleeding gums Yes No Sensitivity to Cold Yes No Dry Mouth Yes No Sangrado de las encías Sensibilidad al frío Sequedad en la boca Grinding Teeth Yes No Sensitivity to Hot Yes No Broken Fillings Yes No Rechinar dientes Sensibilidad al calor Rellenos rotos Loose Teeth Yes No TMJ Pain Yes No Sores/ growth in mouth Yes No Dientes flojos Dolor en la mandíbula Llagas/crecimiento en boca How often do you floss? _________________________ How often do you brush? ___________________________ ¿Con qué frecuencia usar hilo dental? ¿Con que frequecia se lava los dientes? Date of last visit ______________________________ Fecha de Ultima visita de Dentista__________________________ _________________________________________________________________________________________________________________________________ HEALTH HISTORY Circle either “Yes” or “No” to indicate if you have had any of the following: Marke Si o No en las siguente preguntas AIDS/HIV Yes No Epilepsy Yes No Sinus Trouble Yes No Sida/HIV Epilepsia Problemas del seno Anemia Yes No Fainting or dizziness Yes No Stroke Yes No Anemia Desmayos o mareos Derrame o infarto Arthritis, Rheumatism Yes No Glaucoma Yes No Thyroid Problems Yes No Artritis, reumatismo Glaucoma Problemas de la tiroides Artificial Heart Valves Yes No Headaches Yes No Tonsillitis Yes No Válvulas cardíacas artificiales Dolor de cabeza Amigdalitis Artificial Joints Yes No Heart Murmur Yes No Tuberculosis Yes No Articulaciones artificiales Soplo en el corazón Tuberculosis Asthma Yes No Heart Problems Yes No High Blood Pressure Yes No Asma Problemas del corazón Presión arterial alta Bleeding abnormally Yes No Kidney Disease Yes No Shortness of Breath Yes No Sangrado anormal Enfermedad del riñón Dificultad para respirar Extractions or surgery Yes No Liver Disease Yes No Emphysema Yes No Extracciones o cirugía Enfermedad del hígado Enfisema Blood disease Yes No Mitral Valve Prolapse Yes No Rheumatic Fever Yes No Enfermedad de la sangre Prolapso de válvula mitral Fiebre reumática Cancer Yes No Pacemaker Yes No Diabetes Emphysema Yes No Cancer Marcapasos Diabetes enfisema Chemotherapy Yes No Radiation Treatment Yes No Respiratory Disease Yes No Quimioterapia Tratamiento de radiación Enfermedades respiratorias Congenital Heart Lesions Yes No Pregnant Yes No Lesiones congénitas del corazón Embarazada How many months?___________ Cuantos Meses?________________ _________________________________________________________________________________________________________________________________________________________ ALLERGIES _______ Asprin (Aspirina) ________ Sulfa List of Medications you are taking: _______ Penicillin (Penicilina) ________ Iodine (Yodo) Lista de medicamentos que está tomando: _______ Codeine (Codeína) ________ Other (otro) _______________________________________________________ _______ Latex (Látex) ________________________________________________________ ________ Local Anesthetic (Anestésico local)
______________________________________ How did you hear about our office?__________________________________________________________________ Signature:___________________________________________________________________________ Date:_____________________