Thompson DDS New Patient Child Dental History

1

Patient Name

First Name

Last Name

2

Patient Date of Birth

3

Mother's Name:

First Name

Last Name

4

Phone Number

Area Code

Phone Number

5

Social Security #

6

Father's Name:

First Name

Last Name

7

Phone Number

Area Code

Phone Number

8

Social Security #

9

Name

First Name

Last Name

10

Relation to Patienti.e. parent, legal guardian

11

Do you have dental insurance?

YESNO

12

Insurance Information

Insurance Company

Insurance Co. Phone Number

Subscriber ID#

Policy#

Group#

13

Please upload a photo of the front & back of your insurance card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

14

Any previous unhappy medical or dental visits?

YESNO

15

Has your child complained about any dental problems?

YESNO

16

Any injuries to mouth, teeth, or head?

YESNO

17

Does your child brush daily?

YESNO

18

Complaints or Concerns?Do you have any dental complaints or concerns?

19

Please list all medications and dosages.Ex: Aspirin - 83 mg, once a day (list each on a separate line)

20

Please list all allergies and reactions.Ex: Peanuts - closes my air passage and can't breath - very serious (list each on a separate line)

21

Patient or Guarantor's Signature* This field is required.

Clear

22

Today's Date* This field is required.

Date