Reza Beheshti, D.D.S. Board Certified Pediatric Dentist 2730 University Blvd. W Suite 1010 Wheaton/Silver Spring, MD Tel:

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1 Informacion Sobre su Niño/a Nombre del Niño/a : SSN#: Niño Niña Dirección: Calle Apt.# de Nacimiento: / / Informacion en General de Hoy: / / Board Certified Pediatric Dentist Wheaton/Silver Spring, MD Quien acompaña al niño/a? Nombre: Tiene custodia legal de este niño/a? S N Cual es su idioma de comunicación preferido? Inglés Español Otro Información de los Padres La persona responsable de la cuenta: Estado Civil: Soltero/a Casado/a Acompañado/a Viudo/a Divorciado/a Separado/a Madre Madrastra Guardian Padre Padrastro Guardian Nombre: SSN#: de Nacimiento: / / Dirección: (Si es diferente del niño/a) Calle Apt.# Celular#: ( ) Casa/Trabajo# :( ) Correo Empleador: Nombre: SSN#: de Nacimiento: / / Dirección: (Si es diferente del niño/a) Calle Apt.# Celular#: ( ) Casa/Trabajo# :( ) Correo Empleador: Seguro Dental Tiene seguro dental? S N Tiene seguro dental (Secundario)? S N Nombre de la compañía de seguro dental: Nombre de la compañía de seguro dental: Liberación Yo certifico que mi hijo/ a esta cubierto por Insurance Co. y asigno todas las ventajas del seguro por otra parte pagaderas a mi. Entiendo que es mi responsabilidad para el pago de los servicios dados y también soy responsable de pagar cualquier copago y deducible que mi seguro no cubre Por este medio autorizo al dentista para liberar toda la información necesaria para garantizar el pago de los beneficios. Autorizo el uso de esta firma en todas mis sumisiones de seguros, manual o electrónico. Firma del Padre o Guardian Version: July 2016

2 Historia Medical Nombre del doctor Pediatra: Numero de teléfono del doctor pediatra :( ) 1. Ha experimentado alguna vez su hija/a los siguientes problemas medicos? Para cada SI indique los detalles a continuacion. Soplo Del Corazón S N El rasgo de células falciformes anemia S N Apnea del sueño / ronquido S N Asma S N Enfermedad de células falciformes/anemia S N Problemas de la tiroides o de la hipófisis S N ADD/ ADHD S N Defecto congénito del corazón/enfermedad S N Sangrado anormal (hemofilia) S N Diabetes, hiperglucemia S N Convulsiones / ataques S N Escarlatina S N Problemas del hígado(hepatitis) S N Autismo/ Autismo disroder espectro S N Neumonía S N Problemas de conducta S N Agrandamiento de la amígdalas/ Adenoides S N Tuberculosis S N Trastornos de desarrollo S N Lesión cerebral/ Cerebro cebral S N Anemia S N Eczema S N ERGE (gastro esofágico) S N Cáncer, tumor, otro S N Intolerancia a la lactose S N VIH/ Sida S N Pérdida de audición S N Labio leporino/ paladar S N Handicaps/ Discapacidad S N 2. Si marcó cualquiera de las condiciones médicas anteriores, o si le gustaría hablar de cualquier otra condición médica que su hijo/a tiene/tenía, por favor explique a continuación. 3. Está su hijo/a tomando algún medicamento (con receta o sin receta médica), vitaminas, suplementos, dietéticos? S N Escriba el nombre, dosis, y frecuencia: 4. Ha tenido su hijo/a alguna reacción o alergía a un antibiótico, sedante, anestésicos, cualquier medicamento, o alergia a cualquier otra cosa (como el latex, metal, acrílicos, comida, frutas secas o tinte? S N Por favor explique a continuación : 5. Está su hijo/a al día con las vacunas contra la enfermedad de la infancia? S N 6. Require su hijo/a antibiótico antes del tratamiento dental? S N Yo afirmo que la información que he proporcionado es correcta al mejor de mi conocimiento. Será sostenido en las confianzas más estrictas y es mi responsabilidad informar a esta oficina de cualquier cambio del estado médico de mi hijo/a. Yo autorizo al personal dental a realizar los servicios dentales necesarios que mi hijo/a puede necesitar. Firma del Padre o Guardian Soló Para El Uso De Oficina Soló Para El Uso De Oficina Soló Para El Uso De Oficina Soló Para El Uso De Oficina Soló Para El Uso De Oficina I have verbally reviewed the medical/dental information above with the parent/guardian & patient named herein. Doctor s Comments: Signature of Dentist Date

3 Dentistry for Infants, Children, Young Adults and Special Needs Silver Spring, MD Reconocimiento De Recibo De Aviso De Prácticas De Privacidad *Usted Puede Oponerse a Firmar Este Reconocimiento* He recibido una copia del Aviso de Prácticas de Privacidad de esta oficina. 1-Nombre Del Paciente 2- Nombre Del Paciente 3- Nombre Del Paciente Nombre Del Padre (Print) Firma Uso De Oficina We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: o Individual refused to sign o Communications barriers prohibited obtaining the acknowledgement o An emergency situation prevented us from obtaining acknowledgement o Other (Please Specify)

4 Save a Tree by filling out the online form, ing it to us (info@smilelandpd.com), or by printing just the first 3 pages Wheaton/ Silver Spring, MD Dentistry for Infants, Children, Young Adults and Special Needs NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEATH INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR CHILD S HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY: We are required by applicable federal and state law to maintain the privacy of your child s health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your child s health information. We are required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions or reasonable desires to communicate your child s health information by alternative means or by alternative locations. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. 1 Effective Date: July, 2016

5 Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders and other Electronic Communications: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, text massages, reminder s, postcards, or letters). Additionally we may provide other electronic communications such as s and newsletters unless you request not to receive them. PATENT RIGHTS: Access: You have the right to look at or receive copies of your child s health and dental information. You must provide a written request to obtain access to your child s health and dental information as well as have your child s health and dental records sent to another provider. DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your child s health or dental information for purposes other than treatment, payment, healthcare operations and certain other activities. RESTRICTION: You have the right to request that we place additional restriction on our use or disclosure of your child s health and dental information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your child s health and dental information by alternative means or to alternative locations. You must make your request in writing. AMENDMENT You have the right to request that we amend your child s health and dental information under certain circumstances QUESTIONS AND CONCERNS: If at any time you request more information about our privacy practices, or if you have any questions or concern please contact our office at Effective Date: July, 2016