Patient Referral Form 2025 "*" indicates required fields Δ Date* MM slash DD slash YYYY Name Of Person Making the Referral* First Last Contact phone number*Email* Relationship to the patient*PATIENT INFORMATIONName Of Individual Being Referred to A Gift Of Smiles* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Patient Date of Birth*Gender* Male Female Parent/Legal Guardian* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Phone*Email* CLINICAL INDICATION/REASON FOR REFERRAL*Priority* Urgent (pain,trauma, infection) Routine care Date of last dental examinationDoes patient have current dental xrays?* Yes No I don’t know Name, address and phone number of dentist who performed the most current examination of the patientDoes the patient currently have medical insurance?* Yes No Please provide the name of the medical insurance providerDoes this patient currently have dental insurance?* Yes No Pease provide the name of the dental insurance providerPlease provide any relevant medical, dental or social history for this patientAre there any other agencies or resources involved with this patient that we need to contact?* Yes No Please identify agencies or resources we need to contact*Is there any other relevant information that you would like to provide to us?Please provide contact name, phone number and/or email address who we may contact with any questions and to update application status.*May we leave a voicemail message?* Yes No How did you hear about A Gift Of Smiles Foundation?Check box if YES, leave blank if NO Does the patient’s gums bleed when you brush or floss? Are the patient’s teeth sensitive to cold, hot, sweets or pressure? Is the patient’s mouth dry? Has the patient had any periodontal (gum) treatment? Has the patient ever had orthodontic (braces) treatment? Has the patient had any problems associated with previous dental treatment? Do you have a Public Water Supply? Do you have Well Water? How often does the patient drink water?Check box if YES, leave blank if NO Does the patient have earaches or neck pains? Does the patient have clicking, popping, or discomfort in the jaw? Does the patient have brux or grind their teeth? Does the patient have ulcers or sores in their mouth? Does the patient wear dentures or partials? Has the patient ever had a serious injury to their head or mouth? Is the patient under the care of a physician?*YesNoPhysician's Name First Last Physician's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Physician's Phone NumberDate of Last Physical Exam MM slash DD slash YYYY Has there been any changes to the patient's general health within the past year?* Yes No If yes, what condition is being treated?Has the patient had a serious illness, operation or been hospitalized in the past 5 years?* Yes No If yes, what was the illness or problem?Is the patient taking or has the patient taken any prescription or over-the-counter medications?* Yes No If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:Is the patient taking or scheduled to begin taking an antiresorptive agent (Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?* Yes No Since 2001, was the patient treated or were they presently scheduled to begin treatment with an antiresorptive agent (Aredie, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?* Yes No If yes, Date treatment began: MM slash DD slash YYYY Does the patient use controlled substances (drugs)?* Yes No Is the patient taking birth control pills or hormonal replacement?* Yes No Does the patient have a persistent cough greater than a 3-week duration?* Yes No Does the patient have a cough that produces blood?* Yes No Has the patient been exposed to anyone with tuberculosis?* Yes No Is the patient allergic to or have they had a reaction to the following (Check box if YES, leave blank if No) If you answer YES, please specify type of reaction Local anesthetics Asprin Penicillin or other antibotics Barbiturates, sedatives, or sleeping pills Sulfa drugs Codeine or other narcotics Metals Latex (rubber) Iodine Hay fever/seasonal Animals Food Other Other Reaction Not Listed Above:Please specify the type of reaction here:Has the patient ever had an orthopedic total joint (hip, knee, shoulder, elbow, finger replacement)?* Yes No If yes, Date: MM slash DD slash YYYY Check box if YES, leave blank if NO. Does the patient have any of the following complications: Artificial (prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart Unrepaired, cynanotic Congential Heart Disease Repaired (completely) Congential Heart Disease in last 6 months Repaired Congential Heart Disease with residual defects Cardiovascular disease Angina Arteriosclerosis Congestive heart failure Damaged heart valves Heart attack Heart murmur Low blood pressure High blood pressure High Cholesterol Other congenital heart defects Mitral valve prolapse Pacemaker Rheumatic heart disease Abnormal bleeding Anemia Blood transfusion If yes, Date: MM slash DD slash YYYY Check box if YES, leave blank if NO. Does the patient have any of the following complications: Hemophilia AIDS or HIV infection Arthritis Autoimmune disease Rheumatoid arthritis Systematic lupus erythematosus Asthma Bronchitis Emphysema Sinus Trouble Tuberculosis Chest pain when you’re active due to Cancer/Chemotherapy/Radiation treatment Chronic pain due to Cancer/Chemotherapy/Radiation treatment Diabetes – Type I Diabetes – Type II Eating disorder Malnutrition Gastrointestinal disease G.E. Reflux/persistent heartburn Ulcers Thyroid problems Stroke Glaucoma Hepatitis, jaundice, or liver disease Epilepsy Fainting spells or seizures Neurological disorders Kidney problems Osteoporosis Persistent swollen glands in neck Sexually transmitted disease Excessive urination Severe or rapid weight loss Sleep disorder Night Sweats Snoring Does the patient have any Mental disorders?*YesNoIf yes, specify:Does the patient have any Recurrent infections?*YesNoWhat type of infection:Check box if YES, leave blank if NO. Does the patient have any disease, condition, or problem not listed that you think we should know about?YesNoIf yes, Please explain:Signature. 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 that 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 the patient. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I or patient will not hold my/patient's 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/Legal Guardian’s SignatureHow did you hear about us?Website, Social Media, by someone, or other. If ‘by someone’ please include the name of the person and their phone number. Or list the ‘other’ source.A Gift of Smiles will usually take photos and videos of the patient and their caregivers while in the clinic/office. We use these photos/videos for our website, social media and fundraising efforts on various platforms.* I acknowledge HIPPA PRIVACY AUTHORIZATION FORMAuthorization for Use or Disclosure of Protected Health Information (Required by the Health INsurance Portability and Accountability Act —45eFR Parts 160 and 164)A. I give authorization for release of my protected health information (PHI) to A Gift of Smiles regarding my billing, condition treatment and prognosis to the following individual(s): Name:* First Last Relationship:*Phone*Name* First Last Relationship:*Phone*B. I understand that I have the right to revoke this authorization verbally and/or in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. C. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.*Date* MM slash DD slash YYYY DENTAL TREATMENT CONSENT FORMI, (being the parent or guardian of the above minor patient) do hereby authorize and request the performance of dental services for this patient and the use of whatever procedues Dr. Ashby may deem necessary during treatment. I understand that Dr. Ashby and other authorized personnel as he/she may designate to treat the above named patient will use restorative, oral surgery and patient management techniques that are reasonable, necessary and advisable. I also authorize the administration of anesithetics or analgesics which may be deemed advisable by Dr. Ashby. All treatment and procedures will be discussed with you before the appointment. This authorization is valid until revoked by me in writing. SIGNATURE of Parent/Guardian/Self (if over 18):*Relationship to Patient*Date MM slash DD slash YYYY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIESI, [Please input Name of Parent, Legal Guardian or self if 18 or over], have received/read a copy of this office's Notice Of Privacy Practices.* First Last Signature*Date* MM slash DD slash YYYY FOR OFFICE USE ONLY:
