www.dentalvirtue.com - Patient information form (Minor)

Welcome

We are pleased to welcome you to Virtue Dental Care. Please take a few minutes to read and fill out this form completely. If you have any questions, we are glad to help you.
Patient information-Under 18 Years Old
Child’s Name *

First Name Middle Name Last Name
Preferred Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell Phone *

Area Code Phone Number
Sex *
Birth Date *

Month Day Year
Date
School Name
Grade
Hobbies/Sports
Whom may we thank for referring you
Notify in case of emergency *
Phone *

Area Code Phone Number
Primary Insurance
Person responsible for Account

First Name Middle Name Last Name
Relation to patient
Birth Date

Month Day Year
Date
Soc Sec #
Address (if different from patient)

Street Address

Street Address Line 2

City State

Zip Code
Home Phone

Area Code Phone Number
Responsible Person employed by
Insurance Company
Phone

Area Code Phone Number
Subscriber ID#
Group #
Dental History
What would you like us to do for your child today?
Is your child experiencing dental discomfort today?
Has your child ever experienced a mouth or chin injury?
Please select any of the following that applies to your child

Tooth grinding Nail-biting Biting on other objects Suck thumb Suck pacifier Suck finger(s)
Was your child breast fed? *

Yes No
If yes, how long? *
Does your child have speech problems? *

Yes No
Date of last dental visit?

Month Day Year
Date
Date of last x-rays?

Month Day Year
Date
Do you monitor or help with brushing?
How often does your child brush their teeth?
Floss?
How do you feel about the appearance of your child’s teeth/smile?
Has your child ever experienced an adverse reaction to dental anesthetic?
Does your child consume (select all that apply)?

Milk Soda Juice Tea Sports drinks
Medical History
Child’s Physician’s Name

First Name Last Name
Phone

Area Code Phone Number
Date of last visit

Month Day Year
Date
Has your child had any illnesses, operations, hospital stays? *

Yes No
If yes, please explain *
Is your child currently under the care of a physician? *

Yes No
If yes, describe *
Select all that apply to your child

AIDS/HIV Positive Anaphylaxis Anemia Arthritis Artificial heart valve Artificial joint Asthma Allergies (seasonal) Back problems Blood disease Cancer Chemical dependency Chemotherapy Behavioral problems Cough (persistent) Cough with blood Developmental Delays Diabetes Endocrine Epilepsy/Seizures Eye Disorders Fainting Food Allergies Glaucoma Headaches Heart Murmur Heart Problems Hemophilia/bleeding disorder Herpes Hepatitis High Blood Pressure Hearing problems Jaw Pain Kidney problems Liver disease Mitral Valve Prolapse Pacemaker Psychiatric care Radiation therapy Respiratory disease Shingles Skin rash Stroke Tobacco habit Tonsillitis Tuberculosis None
Is your child take current medications? *

Yes No
Please list current medications/dose
Is your child allergic to any of the following

Aspirin Mercury Codeine Penicillin Sulfa Drugs Latex Jewelry/Metals Dental Anesthetic None Other
Authorization
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and informed dental treatment. If there are any changes in my child’s medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for the services rendered. I authorize the use of the signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand I am financially responsible for all charges that were or not paid by insurance.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Payment Is due in full at the time of treatment, unless prior arrangements have been approved
Should be Empty:

Welcome

Patient information-Under 18 Years Old

Primary Insurance

Dental History

Medical History

Authorization