New Patient Forms

Armin Aliefendic, DDS and Associates

1710 N. Business 287, Ste #140 Waxahachie, TX 75165

972-351-9700
New Patient Forms - Acquaintance Record
We sincerely welcome you and your child into our practice. We will make your dental visits as pleasant as we can. In order for us to better understand your child, please complete this form as thoroughly as possible. Thank you.
Child's name*
Nickname
Date of Birth*

MonthDayYear
Date
Age
Gender*

MaleFemale
Weight*
How did you hear about us? Please check all that apply. If you were referred by family or a friend, let us know who so we can thank them!

Tooth FairyCommunity EventMagazine AdInternet / GoogleWalk-in / SignFamily/Friend (please select "Other" and list their name in the box that appears)Other
Who is the child's legal guardian?*
Are parents married, divorced, separated, remarried, or deceased? Any special circumstances that would help us treat your child?*
Parent #1/Legal Guardian Name*
Parent #1: Date of birth*

MonthDayYear
Date
Parent #1: Social Security Number
Parent #1: Driver's License number
Parent #1: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #1: Home Phone*
Please enter a valid phone number.
Parent #1: Cell Phone
Please enter a valid phone number.
Parent #1: Other Phone
Please enter a valid phone number.
Parent #1: Work Phone
Please enter a valid phone number.
Parent #1: Employer
Parent #1: Email*
example@example.com
Parent #2/Legal Guardian Name
Parent #2: Date of Birth

MonthDayYear
Date
Parent #2: Social Security number
Parent #2: Driver's License
Parent #2: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #2: Home Phone
Please enter a valid phone number.
Parent #2: Cell Phone
Please enter a valid phone number.
Parent #2: Other Phone
Please enter a valid phone number.
Parent #2: Work Phone
Please enter a valid phone number.
Parent #2: Employer
Parent #2: Email
example@example.com
Name of siblings? (Place a * by those we have treated)
What is the best method of contact?*

TextPhoneEmail
With whom should we confirm:
Indicate the number or email that will be used to confirm appointments:*
DENTAL INSURANCE INFORMATION
Insured name. If none, type N/A.*
Employer. If none, type N/A.*
Group number
Insurance company. If none, type N/A.*
Insurance company telephone
Please enter a valid phone number.
Subscriber ID Number
DENTAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)
Is this your child's first visit to our office?*

YesNo
What is your main concern for this visit?*
Has your child been seen in any other dental office?*

YesNo
If so, where?
Date of last dental exam:
Date of last x-rays:
Does your child have any mouth related habits such as thumb sucking?*

YesNo
If so, please explain?
Has your child experienced any unfavorable reaction from any previous medical or dental care?*
Does your child brush everyday?*

YesNo
Do you assist with brushing or flossing?*

YesNo
Is your child still breast or bottle feeding?*

YesNo
MEDICAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)
Child's physician*
Date of last visit:*

MonthDayYear
Date
Has your child ever been diagnosed with heart disease or a heart murmur?*

YesNo
If yes, please explain:
Do your child have any shunts, pins, screws, rods or artificial joints?*

YesNo
If yes, please explain:
Has your child ever had surgery?*

YesNo
If yes, please explain:
Is your child in good health?*

YesNo
Has your child had or does he/she have now: ADD/ADHD*

YesNo
Has your child had or does he/she have now: Austim/Asperger's*

YesNo
Has your child had or does he/she have now: Birth defects*

YesNo
Has your child had or does he/she have now: Cleft lip or palate*

YesNo
Has your child had or does he/she have now: Food or pollen allergies*

YesNo
Has your child had or does he/she have now: Allergic reaction to medication*

YesNo
Has your child had or does he/she have now: Sensitivity to artificial coloring/flavoring*

YesNo
Has your child had or does he/she have now: Difficulty with speech*

YesNo
Has your child had or does he/she have now: Hearing loss*

YesNo
Has your child had or does he/she have now: Kidney problems*

YesNo
Has your child had or does he/she have now: Asthma or lung problems*

YesNo
Has your child had or does he/she have now: Blood transfusions*

YesNo
Has your child had or does he/she have now: Emotional, mental or nervous problems*

YesNo
Has your child had or does he/she have now: Heart disease or heart murmur*

YesNo
Has your child had or does he/she have now: Rheumatic fever*

YesNo
Has your child had or does he/she have now: Hepatitis*

YesNo
Has your child had or does he/she have now: Epilepsy or any seizure disorder*

YesNo
Has your child had or does he/she have now: Cerebral palsy*

YesNo
Has your child had or does he/she have now: Prolonged bleeding or hemophilia*

YesNo
Has your child had or does he/she have now: Leukemia*

YesNo
Has your child had or does he/she have now: Tumors or malignancies*

YesNo
Has your child had or does he/she have now: Mouth injuries*

YesNo
Has your child had or does he/she have now: Special needs*

YesNo
If so, please explain:
Is your child taking any medications now?*

YesNo
Please list any current medications:
Please list any allergies:
Are there any other health problems we should be aware of?
Person to contact in case of emergency

(Not living at home)
Name*
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
In order to provide your child with optimum care, we draw upon the knowledge of our entire staff of doctors in consultation, diagnosis and treatment of all patients. The undersigned hereby authorizes this dental office to perform the examination and after explanation, the necessary dental services deemed appropriate for the care of the above named child and furthermore, will be responsible for charges incurred from said dental patient.
Parent signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Forms - Acquaintance Record

DENTAL INSURANCE INFORMATION

DENTAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)

MEDICAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)

Person to contact in case of emergency