• New Patient Form

  • Tell Us About Your Child

    Today's Date:   Pick a Date*   
    Best phone to reach you at:   *             
    Birthdate:   Pick a Date*   Child's Age:   *   
    Nickname:            
    School: Grade:
    Child's Home Address:                  
    What patient or physician can we thank for referring you?      

  • Parent's Information

    Parent's Marital Status: 
                      
    Parent 1:   *   *   Social Security #:      
    Birthdate:   Pick a Date*   Email Address:      
    Employer:      Home Phone:     
    Work Phone:     Cell Phone:     

  • Parent 2:   *   *   Social Security #:      
    Birthdate:   Pick a Date*   Email Address:      
    Employer:      Home Phone:     
    Work Phone:     Cell Phone:     

  • Insurance Information

    Primary Insurance - Dental Coverage            
    Insured's Name:      Relationship to Patient:      
    Insured's Birthdate:   Pick a Date   Insured's ID#         
    Insured's Employer:      Insurance Co Name:      
    Phone #:      Group #      
    Insurance Co. Address:                  

  • Secondary Insurance - Dental Coverage            
    Insured's Name:      Relationship to Patient:      
    Insured's Birthdate:   Pick a Date   Insured's ID#         
    Insured's Employer:      Insurance Co Name:      
    Phone #:      Group #      
    Insurance Co. Address:                  

  • Dental History
    Is the child currently in pain?       
    What is the primary reason for today's visit?      
    Has the child experienced problems with previous dental work?          
    Does the child brush his/her teeth daily?        
    Floss his/her teeth daily?        
    Has the child had sealants in the past?        
    Date of last dental xray?      
    Dentist:            
    Last visit:   Pick a Date   Phone #:      
    Why did you leave your previous dentist?      
    What did you like most about any dentist you have seen?      
    How do you think your child will do today?      

  • Does/did the child have any of the following habits?
       * Lip Sucking/Biting
       * Mouth Breather  
       * Used Pacifier
       * Nursing Bottle Habits
       * Clenching/Grinding Teeth
       * Nail Biting
       * Speech Problems
       * Tongue Thrust
       * Tongue/Cheek Biting
       * Thumb/Finger Sucking
       * Chewing On Objects
       * Breast Fed

  • Medical History
    Child's Physician:  Phone:  Last Visit:Pick a Date
    Address:                  
    Is the child currently under the care of a physician?         
    Please explain:      
    Please describe the child's current physical health:            
    Are immunizations current?         
    Please list all of the drugs the child is currently taking:      
    Is your child allergic to any of the following:                           
    Does your child have any medical conditions that require Pre-Med?         
          

  • Has the child had/experienced any of the following:
       * Abnormal Bleeding
       * Anemia  
       * Any Hospital Stay/Operations
       * Asthma
       * Autism Spectrum
       * Birth Defects
       * Blood Transfusions
       * Cancer
       * Cerebral Palsy
       * Chronic Ear Infections/Tubes
       * Cystic Fibrosis
       * Delayed Speech Development
       * Developmental Delay
       * Diabetes
       * Down Syndrome
       * Emotional/Psychiatric Problems
       * Epilepsy
       *   Food Allergies             
       *   G-Tube Feeding
       *   Hearing Loss/Impairment
       *  Heart Condition/Murmur
       *   Hepatitis
       *   HIV/AIDS
       *   Hyperactivity/ADHD
       *   Kidney Disease
       *   Learning Disabilities
       *   Liver Disease
       *   Muscular Dystrophy
       *   Radiation Therapy
       *   Rheumatic Fever
       *   Seizures
       *   Seasonal Allergies
       *   Sickle Cell Anemia
       *   Skin Disorders
       *   Sleep Apnea/Snoring
       *   Spina Bifida
       *   Tonsillitis
       *   Tuberculosis (TB)
       *   Tumors
       *   Syndrome (specify)

  • Authorization

    I affirm that the information I have is correct to the best of my knowledge, and that it is my reponsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary services that my child may need. I assign the Doctor to all my insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover. 

  • Clear
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    Pick a Date
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