Tell Us About Your ChildToday's Date: Date* Best phone to reach you at: Phone Number* Mobile Home Work Birthdate: Birthdate* Child's Age: Age* Nickname: Nickname Male Female School: School Name Grade: Grade Child's Home Address: Street Address City State Zip What patient or physician can we thank for referring you?
Parent's InformationParent'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 InformationPrimary 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 HistoryIs 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?
Does/did the child have any of the following habits?Yes No* Lip Sucking/BitingYes No* Mouth Breather Yes No* Used Pacifier Yes No* Nursing Bottle HabitsYes No* Clenching/Grinding TeethYes No* Nail BitingYes No* Speech ProblemsYes No* Tongue ThrustYes No* Tongue/Cheek BitingYes No* Thumb/Finger SuckingYes No* Chewing On ObjectsYes No* Breast Fed
Medical HistoryChild's Physician: Phone: Phone Number Last Visit:DateAddress: 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
Has the child had/experienced any of the following:Yes No* Abnormal BleedingYes No* Anemia Yes No* Any Hospital Stay/Operations Yes No* AsthmaYes No* Autism SpectrumYes No* Birth DefectsYes No* Blood TransfusionsYes No* CancerYes No* Cerebral PalsyYes No* Chronic Ear Infections/TubesYes No* Cystic FibrosisYes No* Delayed Speech DevelopmentYes No* Developmental DelayYes No* DiabetesYes No* Down SyndromeYes No* Emotional/Psychiatric ProblemsYes No* EpilepsyYes No* Food Allergies Yes No* G-Tube FeedingYes No* Hearing Loss/ImpairmentYes No* Heart Condition/MurmurYes No* HepatitisYes No* HIV/AIDSYes No* Hyperactivity/ADHDYes No* Kidney DiseaseYes No* Learning DisabilitiesYes No* Liver DiseaseYes No* Muscular DystrophyYes No* Radiation TherapyYes No* Rheumatic FeverYes No* SeizuresYes No* Seasonal AllergiesYes No* Sickle Cell AnemiaYes No* Skin DisordersYes No* Sleep Apnea/SnoringYes No* Spina BifidaYes No* TonsillitisYes No* Tuberculosis (TB)Yes No* TumorsYes No* Syndrome (specify)
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.