blivaissdds - Child Registration & Health History

Child's Registration & Health History Questionnaire

You, as a parent, want to help your child to good oral health. Modern science is making many important contributions to better oral health, but the individual must still take the major responsibility for the care of his/her own mouth. You can teach your child to do so. With proper personal and professional care, your child may keep his/her teeth all their life.
Date

MonthDayYear
Child Name
Date of Birth

MonthDayYear
Social Security Number
School
Grade
Residence

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Father's Name
Address
Address (if different)

Street

CityState

Zip Code
House Phone (if different)

Area CodePhone Number
Cell Phone
Cell Phone
How Long
Employed By
Work Phone

Area CodePhone Number
Mothers Name
Address
Address (if different)

Street

CityState

Zip Code
House Phone (if different)

Area CodePhone Number
Cell Phone
How Long
Employed By
Work Phone

Area CodePhone Number
DENTAL INSURANCE
Subscriber
Birthdate

MonthDayYear
Social Security Number
Member ID
Insurance Company
Group Number
Claim Mailing Address
insurance company phone number

Area CodePhone Number
Are you interested with dental insurance plan ?

YesNo
Name of Insurance Company
Policy Number
Union (Local #)
Union head
Person responsible for payment
Any brothers or sisters

YesNo
If yes list first name & age
Is this your child first dental experience ?
What is the child's attitude towards the visit ?
Comments
Whom may we thank for referring you to our office ?

Child's Registration & Health History Questionnaire

DENTAL INSURANCE

MEDICAL HEALTH HISTORY

DENTAL HEALTH HISTORY - CHILD