Tell Us
About
Your Child
Who Is
Accompanying
the Child Today?
Welcome
Today’s Date: Child’s Home Phone #: (
)
Cell Phone #: (
Child’s Name Last First
Nickname: Child’s Birthdate:
MI
)
/
/
Child’s Age:
q Male q
Female School: Child’s Home Address:
Grade:
Street
City State Zip
Name: Relation:
Do you have legal custody of this child? q
Yes q
No Is this child adopted? q
Yes q
No Is the child in a foster home? q
Yes q
No
Whom may we Thank for referring you? Other siblings seen by us:
Neighbor or Relative not living with you
His / Her Name: Relation: Address:
Home Phone: (
Street
)
Cell Phone: (
City )
State Zip
Parent’s Information
Parent’s Marital Status: q
Married q
Divorced q
Separated q
Widowed q
Remarried q
Single E-Mail Address:
Mother qStep Mother q Guardianq Birthdate
/
/
Home Phone#:(
Name: Address:
City Employer: )
State Work Phone#:(
Father qStep FatherqGuardian q Birthdate
/
/
Home Phone#:(
Name: Address:
Cell Phone #:(
Social Security #:
Street
)
)
Cell Phone #:(
Zip
)
)
Social Security #:
Street
City Employer: Work Phone#:(
State )
Zip
E-Mail
Appointments
Who is Responsible for Making Appointments
Name: Work Phone: (
)
Relationship: Home Phone: (
) Name: Work Phone: (
)
) Insurance Information
Insurance Co. Address:
Street
/
Employer’s Address:
Street
Street
Zip
State Zip
Policy Owner’s Employer:
/
) State Zip
State Zip
Relationship to Patient:
ID # or Social Security #: Street
Group # (Plan, Local or Policy #):
City Policy Owner’s Name: State Relationship to Patient:
Orthodontic Coverage? qYes q
No
Insurance Co. Address:
/
Group # (Plan, Local or Policy #):
City Insurance Co. Name Phone #: (
Employer’s Address:
) ID # or Social Security #: Dental Coverage? q
Yes q
No Policy Owner’s Birthdate:
)
City Policy Owner’s Name: /
Cell (
Orthodontic Coverage? qYes q
No
Insurance Co. Name Phone #: (
Policy Owner’s Birthdate:
)
Relationship: Home Phone: (
Dental Coverage? q
Yes q
No Cell (
City Policy Owner’s Employer:
Is your child currently in pain? qYes q
No What is the primary reason for today’s visit?
Dental History
Has the child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)? qYes q
No
Has the child experienced problems with previous dental work? qYes qNo
Is the child’s water fluoridated? qYes qNo Is the child taking fluoridated supplements? qYes q
No
Does the child brush his / her teeth daily? qYes qNo
Floss his / her teeth daily? Previous Dentist:
qYes q
No
Date of Last Visit:
Does / Did the child have any of the following habits?
Y N
Breast Fed
Y N
Mouth Breather Y N
Thumb / Finger Sucking
Y N
Chewing on Objects
Y N
Nail Biting Y N
Tongue / Cheek Biting
Y N
Clenching / Grinding Teeth
Y N
Nursing Bottle Habits
Y N
Tongue Thrust
Y N
Lip Sucking / Biting
Y N
Speech Problems Y N
Used Pacifier
Child’s Physician:
Phone #: (
)
Date of Last Visit
Clinic
Is the child currently under the care of a physician? qYes qNo
City State
Please explain:
Please describe the child’s current physical health: q
Good qFair q
Poor
Are Immunizations Current? qYes qNo
Please list all drugs that the child is currently taking:
Medical History
Please list all drugs and / or other things that cause the child allergic reactions:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Abnormal Bleeding
AIDS / HIV+ Allergies
Anemia Any Hospital Stays / Operations
Asthma
Blood Transfusion
Cancer
Chicken Pox
Congenital Heart Defect Convulsions
Has the child had
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
/ experienced any of the following:
N Diabetes
N Epilepsy
N Handicaps / Disabilities
N Hearing Impairment N Heart Murmur
N Hemophilia
N Hepatitis
N High Blood Pressure
N Hives
N Kidney Problems
N Liver Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Low Blood Pressure
Lupus
Measles
Mitral Valve Prolapse
Mononucleosis
Rheumatic Fever
Scarlet Fever
Sickle Cell Anemia
Skin Rash
Tonsillitis
Tuberculosis (TB)
Late
Charges
Authorization
& Release
HIPPA
Please discuss any serious medical problems the child experiences/ed: I Parent or Guardian Name
have received a copy of this office’s Notice of Privacy Practices.
I understand that providing incorrect information can be dangerous and it is my responsibility to inform the office of any changes in the child’s medical status. I also authorize the staff to perform
the necessary services the child may need.
I also authorize the release of any information including the diagnosis and the records of treatment or examination rendered, to third party payers and/or other health practitioners. I authorize and
request my insurance company to pay directly to the Dentist or Dentist’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for
services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. The parent or guardian who accompanies the child is responsible for the account.
Signature of patient (or parent/guardian if minor)
Date
If I do not pay the entire new balance within 90 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I
realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In
the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.
Thank you for filling out this form completely.
The information you have provided will help us serve your child’s dental healthcare needs more effectively and effiCiently.
If you have any questions at any time, please ask us. We are always happy to help.