About Your Child
Child's First Name
*
Child's Last Name
*
Child's Preferred Name
*
Age
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Gender
*
Please Select
Male
Female
Gender Diverse
Child's Birthday
-
Month
-
Day
Year
Date
Height (in)
*
Weight (lbs)
*
Reason for this visit?
*
Were you referred by a local doctor or dentist?
(we wish to thank them!)
How did you hear about us?
*
Doctor
Dentist
Friend/Family Member
Online/Social Media
Other
Referring Doctor's Name
*
Referring Doctor's Phone
-
Area Code
Phone Number
Referring Dentist's Name
*
Referring Dentist's Phone
-
Area Code
Phone Number
Referring Friend/Family Member's Name
Online/Advertising
*
Google
Bing
Yahoo
Facebook
Instagram
TV
Radio
Billboard
Drove by Office
Other
More Information
Child's First Dental Visit?
*
Yes
No
Child's Previous Dentist
Previous Dentist Name
*
City of Previous Dentist
*
Dental History
Date of Last Exam
*
Date of Last X-Ray
*
Any injuries to your child's teeth or jaw?
*
Yes
No
When? and What (injuries)?
*
History of breast feeding?
*
Yes
No
Dates for breast feeding
*
Bottle Fed?
*
Yes
No
Describe bottle habits, include dates
Thumb/finger sucking?
*
Yes
No
Describe thumb/finger sucking habits, include dates
Pacifier use?
*
Yes
No
Describe pacifier habits, include dates
Dental Grinding or Clinching?
*
Yes
No
When (grinding/clinching)?
*
Has your child experienced any unfavorable reaction from previous medical or dental care?
*
Yes
No
Please explain any reactions...
*
Has your child had recent dental pain?
*
Yes
No
Please explain any pain...
*
Preventative Dental History
How often does your child brush?
*
Please Select
4+ times a day
3 times a day
2 times a day
1 time a day
every other day
twice a week
once a week
rarely or never
Is toothbrushing supervised?
*
Yes
No
Does your child receive fluoride in vitamins?
*
Yes
No
Does your child receive fluoridated water?
*
Yes
No
Does your child receive fluoride tablets/drops?
*
Yes
No
Does your child receive bottled water?
*
Yes
No
Does your child receive well water?
*
Yes
No
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Medical History
How do you think your child will act to the Dentist?
*
Is your child presently under the care of your family physician for any medical reason?
*
Yes
No
Why or what is the reason?
*
Date of last Physical Exam
*
Family Physician's Name
*
Physician's Address
*
Physician's Phone
*
Is your child presently under the care of a specialist for any medical reason?
*
Yes
No
Specialist's Name
*
Specialist's Phone
*
Does your child have a history of health problems?
*
Yes
No
Please explain health problems
*
Is your child presently taking any medications?
*
Yes
No
Please explain medications
*
Are antibiotics necessary for dental work because of a heart murmur, heart defect, prosthesis, shunt, or other medical reason?
*
Yes
No
Is your child allergic to a drug or drug product?
*
Yes
No
Please explain drug or product allergies
*
Has your child had a history of taking medications frequently?
*
Yes
No
Please explain frequent medications
*
Has your child ever been hospitalized or had surgery?
*
Yes
No
Please explain major medical events
*
Is your child allergic to any environmental pollutants?
*
Yes
No
Please explain pollutant allergies
*
Is your child allergic to any medications?
*
Yes
No
Please explain medication allergies
*
Is your child allergic to any dyes or foods?
*
Yes
No
Please explain food or dyes allergies
*
Has any member of the family, including your child, had a problem with a general anesthetic?
*
Yes
No
Please explain GA problems
*
Is your child allergic to any metals (snaps)
*
Yes
No
Please explain metal allergies
*
Is your child allergic to latex?
*
Yes
No
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Medical History Continued
Has your child ever been diagnosed as having any of the following conditions?
*
Growth & Developmental Problems
AIDS-HIV
Anemia
Arthritis
Asthma
Autism
Bladder Conditions
Blood Transfusions
Blood Disease
Birth Defects
Bone or Joint Problems
Brain Injury
Bruising Easily
Cancer or Malignancies
Cerebral Palsy
Chemotherapy/Radiation
Child Abuse
Chronic Adenoid/Tonsil Infection
Chronic Ear Infections
Cleft Lip/Palate
Congenital Heart Lesion
Convulsions/Seizures
Developmentally Disabled
Diabetes
Drug Addiction
Ear Stuffiness, Itching or Noises
Emotional Disturbance
Epilepsy
Excessive Bleeding Problem
Excessive Gagging
Eye Problem
Fainting or Dizziness
Fever Blisters
Headaches
Hearing/Speech Impairments
Heart Murmur/Defect
Heart Surgery
Hemophilia
Hepatitis or Liver Disease
High Blood Pressure
Hyperactivity/ADD
Kidney Disease
Leukemia
Mental Disability
Mouth sores
Nutritional Deficiency
Orthopedic Problems
Pain in Jaw Joints
Premature Birth
Psychiatric Care
Rheumatic Fever
Scoliosis
Sickle Cell Anemia
Tuberculosis
None
Other
Other symptoms, medical issues, or changes to your health?
Do you wish to talk to the doctor privately about a special concern?
*
Yes
No
Any notes for the Doctors?
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Parent/Responsible Party
Parent's Name
*
First
Last
Parent Email
*
Parent's Relationship to child?
*
Parent's Cell Phone
*
Parent's Secondary Phone
Parent's Birthday
*
Parent's Social Security Number
Parent's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Employer
*
Employer Phone
*
Occupation
*
Do you wish to list a second parent?
*
Yes
No
Second Parent/Guardian Name
*
Second Parent's Email
*
Second Parent's Relationship to child?
*
Second Parent Cell Phone
*
Second Parent Secondary Phone
*
Second Parent Birthday
*
Second Parent's Social Security Number
Is the second parent's address the same as above?
*
Yes
No
Second Parent's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Parent's Employer
*
Employer Phone
*
Occupation
*
Emergency Contact
Emergency Contact (Other than parent(s) listed above)
*
First Name
Last Name
Emergency Contact's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Main Phone
*
Relationship of Emergency Contact
*
I understand that I am responsible for all charges incurred by me or my family regardless of insurance coverage and that PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. If my account requires servicing by a collection agency or by an attorney I understand that I will be liable for the collection fees, attorney fees and applicable court costs, in addition to my outstanding balance. I also request that payment under my dental insurance program be made directly to Children's Dentistry on any unpaid bills. I authorize the release of any dental information necessary to process this claim and all future claims.
*
I authorize
Authorization First & Last Name
*
First Name
Last Name
Authorization Date
*
-
Month
-
Day
Year
Date
Authorizer Relationship to Child
*
The permission of a parent or guardian is necessary for dental treatment of a minor: I give the doctors permission to use such measures as deemed necessary in their professional judgment to render a diagnosis for my child. This would include an oral examination, radiographs (X-rays) and other diagnostic aids. I have given an accurate report of my child's physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions that my child's medical doctor has advised me should be reported to a dentist.
*
I give permission
Permission Date
*
-
Month
-
Day
Year
Date
Submit
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