New Patient Form

Parent's Information

Parent's Marital Status: 
Married   Divorced   Widowed   Remaried   Single   Partnered   
Parent 1:   First Name   Last Name   Social Security #:   SS number   
Birthdate:   Birthdate   Email Address:   Email   
Employer:   Employer   Home Phone:  Phone Number   
Work Phone:  Phone Number   Cell Phone:  Phone Number   

Parent 2:   First Name   Last Name   Social Security #:   SS number   
Birthdate:   Birthdate   Email Address:   Email   
Employer:   Employer   Home Phone:  Phone Number   
Work Phone:  Phone Number   Cell Phone:  Phone Number   

Insurance Information

Primary Insurance - Dental Coverage   Yes   No      
Insured's Name:   Name   Relationship to Patient:   Relationship   
Insured's Birthdate:   Date   Insured's ID#         
Insured's Employer:   Employer   Insurance Co Name:   Insurance Co   
Phone #:   Phone Number   Group #   Plan, Local or Policy #   
Insurance Co. Address:   Street Address      City   State   Zip   

Secondary Insurance - Dental Coverage   Yes   No      
Insured's Name:   Name   Relationship to Patient:   Relationship   
Insured's Birthdate:   Date   Insured's ID#         
Insured's Employer:   Employer   Insurance Co Name:   Insurance Co   
Phone #:   Phone Number   Group #   Plan, Local or Policy #   
Insurance Co. Address:   Street Address      City   State   Zip   

Dental History
Is the child currently in pain? Yes No      
What is the primary reason for today's visit?   Reason for visit   
Has the child experienced problems with previous dental work? Yes   No      
Does the child brush his/her teeth daily? Yes   No    
Floss his/her teeth daily? Yes   No    
Has the child had sealants in the past? Yes   No    
Date of last dental xray?   Date    
Dentist:      Previous   Present   
Last visit:   Date   Phone #:   Dentist Phone   
Why did you leave your previous dentist?   Why you left   
What did you like most about any dentist you have seen?   Liked most   
How do you think your child will do today?      

Medical History
Child's Physician:  Phone: Phone Number Last Visit:Date
Address:   Street Address      City   State   Zip   
Is the child currently under the care of a physician?   Yes   No   
Please explain:   Explain   
Please describe the child's current physical health:   Good   Fair   Poor   
Are immunizations current?   Yes   No   
Please list all of the drugs the child is currently taking:   Current medications   
Is your child allergic to any of the following:   Asprin   Penicillin   Codeine   Acrylic   Metal   Latex   Local Anesthetics   Nut Allergy   
Does your child have any medical conditions that require Pre-Med?   Yes   No