New Patient Form &#8211; Stowers Pediatric Dentists

New Patient Form
Your Child/Primary Contact Information
Name*
Prefers to be called
Birth Date*

MonthDayYear
Date
Gender*

MF
Email*
Address*
City*
State*
ZIP*
Phone*
Cell
Other than parent, whom shall we contact in case of emergency
Relationship
Phone
Other children & their age(s)
Whom may we thank for referring you
Parent Information
Relationship*

MotherFatherStepmotherStepfatherGuardian
Name*
Birth Date*

MonthDayYear
Date
Address*
City*
State*
ZIP*
Cell Phone*
Cell
Driver's license number*
SSN*
Employer*
Occupation*
Work Phone
Work Address
Work City
Work State
Work ZIP
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Parent Information
Relationship

MotherFatherStepmotherStepfatherGuardian
Name
Birth Date

MonthDayYear
Date
Address
City
State
ZIP
Home Phone
Cell
Driver's license number
SSN
Employer
Occupation
Work Phone
Work Address
Work City
Work State
Work ZIP
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Dental Insurance Information
Name of insured*
Relationship to patient*
Birth Date*

MonthDayYear
Date
SSN
Employer*
Occupation
Work Phone
Address
City
State
ZIP
Dental insurance company*
Payor number
Group number
Policy/ID number*
Insurance company phone*
Additional Dental Insurance Information (If Applicable)
Name of insured
Relationship to patient
Birthdate
Driver's license number
SSN
Employer
Occupation
Work Phone
Address
City
State
ZIP
Dental insurance company
Payor number
Group number
Policy/ID number
Insurance company phone
Health History
It is important we know your child's health! Please answer all questions!
Child's Primary Care Physician*
Phone*
City*
Date and reason for last medical visit*
Medical
If you respond yes to the questions below please explain in the provided boxes.
Is your child under treatment by a physician?*

YesNo
Is your child taking any medications (prescription, over-the-counter)?*

YesNo
Medications (Dosages)
Has your child ever been seriously sick, hospitalized or had surgery?*

YesNo
Does your child have any physical, mental or emotional disabilities?*

YesNo
Is your child allergic to any medication or products?*

YesNo
(Such as penicillin, artificial flavors/colors, latex)
Is your child pregnant?*

YesNo
Please check all that apply to your child's current or past medical history.

AsthmaAnemiaBleeding DisordersDiabetesHepatitisInfectious DiseasesKidney or Liver DisorderChildhood Disease (Mumps, Measles)Heart DisordersSickle Cell DiseaseCancerSeizuresDown syndromeTuberculosisRecurrent Ear InfectionsAIDS/HIVCerebral PalsyEpilepsy
Dental
Is your child experiencing pain/discomfort/swelling or toothaches?*

YesNo
Has your child experienced any significant trauma to the face or jaw?*

YesNo
Do you have any concerns regarding your child's oral health?*

YesNo
(Hygiene, growth and development, habits)
Authorization and Consent for Treatment Form
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk and that it is my responsibility to inform the dental office of any changes in my child's medical/dental status.

I understand that I will be informed of the recommended treatment for my child before any services are rendered and my signature authorizes procedures deemed necessary by the doctors and staff. I agree and understand (regardless of my insurance status), that the parent or guardian who accompanies the child is responsible for payment in full.
Today's Date*

MonthDayYear
Date
Signature*
Should be Empty: