Happy Smiles Dental Group Inc. Intake Form

Please fill out the following form. / Por favor llene el siguiente formulario.

Please Note:
Only patients UNDER 18 YEARS OF AGE can be accompanied by an adult during the consult. Thanks and sorry for the inconvenience.

Solo los pacientes MENORES DE 18 ANOS pueden ser acompanados por un adulto durante la consulta. Gracias y disculpe por la inconveniencia.

First name / Nombre

Last name / Apellido

Date of Birth / Fecha de nacimiento

Social Security #

Gender / Genero

Male / Masculino

Female / Femenino

Phone / Telefono

Email / Correo Electronico

Address / Direccion

Emergency Contact Name / Nombre del Contacto de Emergencia:

Emergency Contact Relationship / Parentesco del Contacto de Emergencia:

Emergency Contact Phone Number / Numero de Telefono del Contacto de Emergencia

Dental History / Historia Dental

Bleeding Gums / Sangramiento de las encias

Yes

Do you have dentures? / Tiene dentaduras postizas?

Yes

Have you ever had braces? / Alguna vez tuvo braces?

Yes

Is your mouth dry? / Tiene resequedad bucal?

Yes

Do you have mouth ulcers? / Tiene ulceras bucales?

Yes

Are you pregnant? / Esta embarazada?

Yes

Are you nursing? / Esta amamantando?

Yes

Medical History / Historia Medica

Heart problems / Problemas cardiacos

Yes

Rheumatic fever / Fiebre reumatica

Yes

High blood presure / Presion alta

Yes

Blood disease / Enfermedad de la sangre

Yes

Hepatitis / Hepatitis

Yes

Epilepsy / Epilepsia

Yes

Cancer / Cancer

Yes

Tuberculosis / Tuberculosis

Yes

Anemia / Anemia

Yes

Liver disease / Enfermedades del higado

Yes

Asthma / Astma

Yes

HIV/AIDS / VIH/SIDA

Yes

Diabetes / Diabetes

Yes

Do you Smoke? / Fuma?

Yes

Other Allergies Please Specify / Otras alergias por favor especifique

Have you been hospitalized in the last 5 years? / Ha estado usted hopitalizado en los ultimos 5 años?

Yes

If you have been hospitalized in the last 5 years, please explain why? / Si usted ha estado hospitalizado en los ultimos 5 años, por favor explique por que?

Are you under medical treatment? / Esta usted bajo tratamiento medico?

Yes

If you are under medical treatment, please explain why? / Si usted esta bajo tratamiento medico, por favor explique por que?

List of medications / Lista de medicamentos

Do you have dental insurance? / Tiene usted seguro dental?

Yes

Name of dental insurance if any / Nombre del seguro dental si tiene alguno

Today's date / Fecha de hoy

Patient/Gardian's signature / Firma del paciente o Guardian

HAPPY SMILES DENTAL GROUP, Inc.

4901 N.W. 4TH STREET., MIAMI, FL 33126

HIPAA

PATIENT ACKNOLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT

I HAVE THE RIGTH TO REVIEW THE NOTICE OF PROVACY PRACTICES PRIOR TO SIGNING THEIS CONSENT, I HAVE BEEN GIVEN THE OPORTUNITY TO READ AND RECEIVE A COPY OF THE HAPPY SMILES DENTAL GROUP, Inc. NOTICE OF PRIVACY PRACTICES.

With my consent, HAPPY SMILES DENTAL GROUP, Inc. may use and disclose protected health information about me to carry out treatment, payment and health care operations (TOP). Please refer to HAPPY SMILES DENTAL GROUP, Inc. Notice of Privacy Practices for a more complete description of such use and disclosures. HAPPY SMILES DENTAL GROUP, Inc. reserves the right to revise its Notice of Privacy Practice at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at HAPPY SMILES DENTAL GROUP, Inc. 4901 N.W. 4th Street, MIAMI, FLORIDA 33126.

With my consent, HAPPY SMILES DENTAL GROUP, Inc. may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. I understand that I have the right to request a restriction on how my information is divulged or mailed, should I wish to exercise this right I understand I need to request it in written.

With my consent, HAPPY SMILES DENTAL GROUP, Inc. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such a appointments reminders card and patient statements as long as they are marked Personal and Confidential. I also understand that I have a right to restrict and limit where my information is sent, should I wish to exercise my right I understand I need to request in written.

I understand that I can request in writing under a separate form, for my medical records to be e-mailed or faxed by HAPPY SMILES DENTAL GROUP, Inc. and that there is a potential that this information may reach unintended parties or that the security of these transactions may be breached in transit. I have the right to request that HAPPY SMILES DENTAL GROUP, Inc. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to HAPPY SMILES DENTAL GROUP, Inc. use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do no sign this consent, HAPPY SMILES DENTAL GROUP, Inc. may decline to provide treatment to me.

Today's Date / Fecha de hoy

Patient/Gardian's Name / Nombre del Paciente o Guardian

Patient/ Gardian's signature / Firma del Paciente o Guardian

For Practice Use Only

Good faith attempt to obtain the signature from the patient. Describe the reason why did the patient did not sign this form:

Staff Member Signature Date

Staff Memeber Name

Staff Memeber Signature

Thanks for submitting!