Raymond J. Tseng, DDS, PhD, PA
351 Wellesley Trade Lane #212, Cary, NC 27519
NEW PATIENT REGISTRATION AND MED/DENT HX FORM
Demographic Information
Patient: __________________________________________________ Today’s Date:______________
Pt. Preferred Name:_________________ Guardian’s Email:___________________________________
Pt. Birthday: ___________________ Age: ________________ Ethnicity: ________________________
Home Address______________________________________ City, State, Zip _____________________
Names and Ages of other children in the family: ____________________________________________
School _________________________________________________ Grade:______________________
Legal Guardian/Contact Information
Parent/Legal Guardian ________________________ Home Phone____________________________
 Yes  No Address Same as Above?___________________________________________________
Relation to Pt________________________________ Email__________________________________
Employer___________________________________ Work Phone_____________________________
Cell Phone__________________ Text Msg Capable: ___Y ___N
Camera/Pic Capable : ___Y ___N
 Yes  No Address Same as Above (if no, list)___________________________________________
Parent/Legal Guardian ________________________ Home Phone____________________________
Relation to Pt________________________________ Email__________________________________
Employer___________________________________ Work Phone_____________________________
Cell Phone__________________ Text Msg Capable: ___Y ___N
Camera/Pic Capable : ___Y ___N
Yes  No Address Same as Above (if no, list)___________________________________________
How may we contact you for appointment reminders (please circle all that apply):
Home Phone
Work Phone
Email
Cell Phone
Text Msg (via Cell)
Who has legal custody of the patient? ____________________________ Dental Insurance: ___Y ___N
Person responsible for payment of account: ____________________ SS#________________________
Who may we thank for referring you to our practice?________________________________________
What is the reason for your child’s dental visit?_____________________________________________
HEALTH HISTORY
Name of Child’s Physician/Group _______________________________Phone #__________________
Mailing Address:___________________________ City ______________ State_______ Zip__________
 Yes  No Is your child in good health? Date of last physical exam__________________________
Yes  No Has your child ever been hospitalized? Please give dates and reasons _______________
_______________________________________________________________________
Yes  No Is your child allergic to anything?_____________________________________________
Yes  No Is your child taking any medications? List name, dose & reason:____________________
_______________________________________________________________________
Yes  No Are your child’s immunizations current?_______________________________________
 Yes  No Were there any problems at birth?___________________________________________
-over-
Medical History (cont’d).
Please indicate if your child has been treated for any of the following:
AIDS/HIV
ADHD/ADD
Adverse Drug Rxns
Anemia
Asthma/Breathing
Autism/ASD
Bleeding/Transfusions
Blood Dyscrasias
Cancer/Tumors
Cerebral Palsy
Cleft Lip/Palate
Congenital Birth Defects
Diabetes
Down’s Syndrome
Endocrine/Growth
Eyesight
Frequent Infections
Heart Disease/murmur
Hepatitis
Kidney Disease
Liver/GI Disease
Mental Delays
MRSA
Opp. Defiance Disorder
Overweight/Obesity
Personality/Social
Physical Delays
Reflux/GERD
Rheumatic Fever
Seizures
Speech/hearing
Other Problems
Please elaborate and/or list other health issues: ________________________________________________________________________
_______________________________________________________________________________________________________________
Do you consider your child’s learning process to be:  advanced  normal  delayed
Was your child  Breast-fed (stopped at__________) Bottle-fed (stopped at:__________)
Dental History
Yes  No Has your child been to the dentist? Date of last x-rays (If taken)___________________
Name of dentist and date:________________________________________________
Yes  No Has your child experienced any unfavorable reaction from previous dental care (Anxiety, fear,
etc)? Explain_________________________________________________________
Yes  No Does your child suck a finger, thumb or pacifier?
Yes  No Does your child have pain or popping associated with chewing, yawning, or opening
wide?
Please check if your child is having problems/you have concerns with any of the following:
 Cavities
 Toothaches
 Sensitive Teeth
 Teeth not falling out
 Trauma
 Gum Infections
 Color of Teeth
 Mouth Odor
 Orthodontics  Jaw Sounds
 Grinding
 Other (specify below)
___________________________________________________________________________________
___________________________________________________________________________________
Yes  No
Yes  No
Yes  No
Yes  No
Is your home water supply fluoridated
Does your child use a fluoride toothpaste?
Do you give your child any other form of fluoride?
Does your child participate in a school fluoride rinse program
Consent for Dental Treatment
I am the parent, legal guardian, or personal representative of the patient and there are no court orders now in effect that
prevent me from signing this consent. The information listed on both sides of this form is complete and accurate to the best of
my knowledge.
I give consent for Dr. Raymond J. Tseng & associated dentists and staff to examine, clean, and provide dental treatment on my
child’s teeth. I further request and authorize dental x-rays as may be considered necessary to diagnose and/or treat my child’s
dental problems. For the purposes of dental research and the advancement of medical/dental education, I will allow
photographs to be taken of my child or child’s teeth for diagnostic, educational, and research purposes. All information
contained in dental chart may be used for educational or research purposes. I am fully aware that any treatment and fees may
change, that I will be responsible for any charges incurred on this child for dental treatment, and that payment is expected in full
at the time of service. I understand it is my responsibility to inform High House Pediatric Dentistry of any changes in my child’s
medical status. I understand this consent is in addition to other consent forms that I have signed.
SIGNATURE:__________________________________________________________ DATE _______________________