cupertinopediatricdentistry

Child's full name

First NameM.I.Last Name
Nickname
Sex

MaleFemale
Age
Date of Birth

MonthDayYear
School
Grade
Reason for visit
Referred to this office by (We wish to thank them)
MEDICAL HISTORY
Child's Physician
City
Phone #

Area CodePhone Number
Date last saw physician (Month / Year)
Is your child presently under the care of a physician for any medical problem ?

YesNo
What ?
Physician Name
Physician Phone #

Area CodePhone Number
Is your child currently taking any medication ?

YesNo
What ?
Has your child ever been hospitalized or had surgery ?

YesNo
If yes for what ?
Is your child allergic to any food or medicine ?

YesNo
What ?
Has your child had a history of :

	Yes	No
ADHD / ADD
Anemia
Allergies
Asthma breathing issues
Autism spectrum
Bleeding disorder
Brain Injury
Cancel malignancy
Cardiac disease murmur
Cerebral palsy

	Yes	No
Chemo / radiation
Cystic Fibrosis
Delayed development
Depression / Anxiety
Diabetes
Down's syndrome
Earaches / Infections
Emotional / School Issues
Epilepsy / Seizure
Hearing Impairment

	Yes	No
Hepatitis
Immune disorder
Kidney / Liver Issues
Muscular disorder
Premature birth
Rheumatic fever
Speech disorder
Tuberculosis
Visual impairment

Does your child have any disease, condition or problem not listed ?

YesNo
If so, what?
DENTAL HISTORY
Child's first dental visit ?

YesNo
Previous dentist
City
Phone #

Area CodePhone Number
Date of last visit
Date of last X-ray
Any injuries to your child's teeth or jaws? (falls, blows, chips, etc)

YesNo
If so, what?
Any history of

Thumb suckingFinger suckingPacifierLip suckingNail BitingNone
Has your child experienced any unfavorable reaction from previous medical or dental care ?

YesNo
Explain
Name of family dentist
City
Phone #

Area CodePhone Number
How often does your child brush ?
Is tooth brushing supervised

YesNo
By whom
Is dental floss used ?

YesNo
Does your child receive

Fluoride toothpasteFluoride in vitaminsFluoride tablets/ dropsFluoridated waterNone
FAMILY INFORMATION
Residence address

Street

CityState

Zip Code

First name of all brothers and sister and their ages

	Name	Relation	Age
1
2
3
4
5

Email
Has any member of your family been a patient in this office before?

YesNo
If yes, name
AUTHORIZATION AND FINANCIAL RESPONSIBILITY
Is your child covered by a dental plan ?

YesNo
Dual Insurance ?

YesNo
Received previous care under this plan ?

YesNo
Father's full name
Social security #
Birthdate

MonthDayYear
Driver's license #
Occupation
Address (If different)
Phone number (If different)

Area CodePhone Number
Employer
Business address
Business phone #

Area CodePhone Number
Name of insurance company
Address of insurance carriers
Group or policy #
Mother's full name
Social security #
Birthdate

MonthDayYear
Driver's license #
Occupation
Address (if different)
Phone Number

Area CodePhone Number
Employer
Business address
Business Phone #

Area CodePhone Number
Name of insurance company
Address of insurance carriers
Group or policy #
To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.

I acknowledge by signing this form, I will be financially responsible for my child’s account.

I hereby authorize DR. MAHNAZ GORGANI, DR. NATALIE VANDER KAM and/or their associates to perform any and all treatment for my above named child and consent to such methods, drugs, and agents as may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled
Signature

Clear
Printed name
Relationship to patient
Date

MonthDayYear
Should be Empty:

MEDICAL HISTORY

Has your child had a history of :

DENTAL HISTORY

FAMILY INFORMATION

AUTHORIZATION AND FINANCIAL RESPONSIBILITY