Madison New Patient Form Pediatric Dentistry

New Patient Form Pediatric Dentistry Madison Office
Preferred Office Selection for First Appointment
Who can we thank for referring you to our office?
Patients Full Name

First NameLast Name
Patients Preferred Name:
Patients Date of Birth

MonthDayYear
Patients Social Security #:
Patients Gender

MaleFemale
Patients Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient E-mail
Phone Number

Area CodePhone Number
Patient Lives With:

First NameLast Name
Primary Guardian:

First NameLast Name
Primary Guardian Relationship to Patient:
Primary Guardian Date of Birth

MonthDayYear
Primary Guardian SS #
Primary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Guardian E-mail
Primary Guardian Mobile Phone

Area CodePhone Number
Primary Guardian Home Phone

Area CodePhone Number
Primary Guardian Occupation
Primary Guardian Employer
Primary Guardian Work Phone

Area CodePhone Number
Primary Guardian Marital Status

MarriedSingleDivorcedWidowed
Primary Guardian Spouse

First NameLast Name
Secondary Guardian:

First NameLast Name
Secondary Guardian Relationship to Patient:
Secondary Guardian Date of Birth

MonthDayYear
Secondary Guardian SS #
Secondary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Guardian E-mail
Secondary Guardian Mobile Phone

Area CodePhone Number
Secondary Guardian Home Phone

Area CodePhone Number
Secondary Guardian Employer
Secondary Guardian Occupation
Secondary Guardian Work Phone

Area CodePhone Number
Secondary Guardian Marital Status

MarriedSingleDivorcedWidowed
Secondary Guardian Spouse

First NameLast Name
May we leave a message about upcoming appointments with
Emergency Contact

First NameLast Name
Emergency Contacts Relationship to Patient
Emergency Contacts Phone

Area CodePhone Number
Emergency Contacts Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please check any of the conditions that apply to the patient

ADHDAutism SpectrumAnemiaAsthmaBrain injuryCancerCerebral PalsyCongenltal Heart DefectConvulsions/SeizuresCystic FibrosisDevelopmentally DelayedDiabetesDrug AbuseEpllepsyEye ProblemsFainting SpellsFever BlistersHearing LossHeart MurmurHemophiliaHepatitisHigh Blood PressureHIV/AIDSHypoglycemiaJaundiceLeukemiaMeaslesOrthopedic ProblemsOtltls (Ear Infection)PneumoniaPregnancyPsychiatric ProblemsRheumatic FeverScarlet FeverSickle Cell AnemiaSpina BlfidaWhooping CoughOther... Please Give Details in Text Box Below
Please describe the condition(s) you have indicated including the history, current treatment or therapy, and any information that might be relevant
Is the patient currently taking any medications?

YesNo
Please list any current or relevant medications being taken
Does the patient have any allergic or adverse reactions to medications?

YesNoUnknown
Please describe any adverse or allergic reactions to medications
Known Common Allergies

AspirinCodeineDental AnestheticsErythromycinJewelryLatexMetalsPenicillinTetracycline
Please List any other allergies known for this patient
Is the patient currently under a Physicians Care?

YesNo
Physicians Name

First NameLast Name
Physicians Phone Contact

Area CodePhone Number
Physicians Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please explain what conditions and any treatments that the patient is under the Physicians care for.
When was the patients last visit or checkup with the physician

MonthDayYear
Please check any of the following conditions that apply to the patient

My child has expressed dental anxiety or fearMy child has had a previous bad experience at a dental officeMy child does receive floride supplimentationMy child brushes his/her teeth dailyMy child requires my assistance in brushing teethMy child sucks his/her thumbs, fingers or pacifier
How would you predict your childs reaction to visiting our staff and office?

GreatGoodNervousPoorNot sure
Describe your child's current oral health
What are your primary concerns about your child's oral health if any?
Is your child covered by insurance?

YesNo
Primary Insurance Company Name
Primary Insurance Company Phone

Area CodePhone Number
Employer Providing Coverage
Employee Name Provided Coverage
Employee SS # Provided Coverage
Primary Insurance Group #
Primary Insurance Policy #
Is your child covered by a Secondary insurance provider?

YesNo
Secondary Insurance Company Name
Secondary Insurance Company Phone

Area CodePhone Number
Secondary Employer Providing Coverage
Secondary Employee Name Provided Coverage
Secondary Employee SS # Provided Coverage
Secondary Insurance Group #
Secondary Insurance Policy #
Signature I agree, sign and initial the Medical/ Dental Release, Filing Insurance Claims Release, and the Privacy Policy Release Forms

Clear
Note: Click here to read our Payment for Services Policy

Note: Click here to read our Practice Guidelines

Note: Click here to read our Notice of Privacy Practices
I have read The following and agree to the terms of usage

Practice Guidelines (see above)Payment for Services Policy (see above)Notice of Privacy Practices (see above)
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New Patient Form Pediatric Dentistry Madison Office