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

Month Day Year
Date
Age
Gender

Male Female
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 Fairy Community Event Magazine Ad Internet / Google Walk-in / Sign Family/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

Month Day Year
Date
Parent #1: Social Security Number
Parent #1: Driver's License number
Parent #1: Address

Street Address

Street Address Line 2

City State / 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

Month Day Year
Date
Parent #2: Social Security number
Parent #2: Driver's License
Parent #2: Address

Street Address

Street Address Line 2

City State / 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?

Text Phone Email
With whom should we confirm:
Indicate the number or email that will be used to confirm appointments:
DENTAL INSURANCE INFORMATION
Insured name
Employer
Group number
Insurance company
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?

Yes No
What is your main concern for this visit?
Has your child been seen in any other dental office?

Yes No
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?

Yes No
If so, please explain?
Has your child experienced any unfavorable reaction from any previous medical or dental care? (please state which)
Does your child brush everyday?

Yes No
Do you assist with brushing or flossing?

Yes No
Is your child still breast or bottle feeding?

Yes No
MEDICAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)
Child's physician
Date of last visit:

Month Day Year
Date
Has your child ever been diagnosed with heart disease or a heart murmur?

Yes No
If yes, please explain:
Do your child have any shunts, pins, screws, rods or artificial joints?

Yes No
If yes, please explain:
Has your child ever had surgery?

Yes No
If yes, please explain:
Is your child in good health?

Yes No
Has your child had or does he/she have now: ADD/ADHD

Yes No
Has your child had or does he/she have now: Austim/Asperger's

Yes No
Has your child had or does he/she have now: Birth defects

Yes No
Has your child had or does he/she have now: Cleft lip or palate

Yes No
Has your child had or does he/she have now: Food or pollen allergies

Yes No
Has your child had or does he/she have now: Allergic reaction to medication

Yes No
Has your child had or does he/she have now: Sensitivity to artificial coloring/flavoring

Yes No
Has your child had or does he/she have now: Difficulty with speech

Yes No
Has your child had or does he/she have now: Hearing loss

Yes No
Has your child had or does he/she have now: Kidney problems

Yes No
Has your child had or does he/she have now: Asthma or lung problems

Yes No
Has your child had or does he/she have now: Blood transfusions

Yes No
Has your child had or does he/she have now: Emotional, mental or nervous problems

Yes No
Has your child had or does he/she have now: Heart disease or heart murmur

Yes No
Has your child had or does he/she have now: Rheumatic fever

Yes No
Has your child had or does he/she have now: Hepatitus

Yes No
Has your child had or does he/she have now: Epilepsy or any seizure disorder

Yes No
Has your child had or does he/she have now: Cerebral palsy

Yes No
Has your child had or does he/she have now: Prolonged bleeding or hemophilia

Yes No
Has your child had or does he/she have now: Leukemia

Yes No
Has your child had or does he/she have now: Tumors or malignancies

Yes No
Has your child had or does he/she have now: Mouth injuries

Yes No
Has your child had or does he/she have now: Special needs

Yes No
If so, please explain:
Is your child taking any medications now?

Yes No
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

City State / 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

Month Day Year
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