Underlined fields are required for submission.
Patient Information
Patient's First Name
Patient's Last Name
Nickname
Patient's Date of Birth
Patient's Sex
M
F
Whom may we thank for referring you to us?
Emergency Contact
Relationship
Home Phone (include area code)
Cell Phone (include area code)
Responsible Party Information
Name of person responsible for this account
Relationship to patient
Phone number
Email
Can we send you appointment reminders by email?
No
Yes
Address
City
State
Zipcode
Primary Insurance Information
Primary Dental Insurance
Insurance Co. Phone Number
Name of Policy Holder
Relationship to patient
Policy Holder birth date
Policy Holder SS#
Member ID
Group Number
Name of Employer
Secondary Insurance Information
Secondary Dental Insurance
Insurance Co. Phone Number
Name of Policy Holder
Relationship to patient
Policy Holder birth date
Policy Holder SS#
Member ID
Group Number
Name of Employer
Dental Information
Is this the child's first visit to a dentist?
No
Yes
Date of last x-rays
Is the child taking any prescription and/or over the counter medications at this time?
No
Yes
If yes, please list:
Is the child allergic to any medications, i.e. Penicillin, Antibiotics or other drugs?
No
Yes
If yes, please explain:
Is the child allergic to anything else, such as certain foods?
No
Yes
If yes, please explain:
Has the child ever had a serious illness?
No
Yes
If yes, when? Please describe:
Has the child ever been hospitalized?
No
Yes
Does the child have a history of other illnesses?
No
Yes
If yes, please list:
DOES THE CHILD HAVE ANY SPEECH DIFFICULTIES?
No
Yes
IS THE CHILD PHYSICALLY, MENTALLY, OR EMOTIONALLY IMPAIRED?
No
Yes
DOES THE CHILD EXPERIENCE EXCESSIVE BLEEDING WHEN CUT?
No
Yes
IS THE CHILD CURRENTLY BEING TREATED FOR ANY ILLNESSES?
No
Yes
HAS THE CHILD HAD ANY PROBLEM WITH DENTAL TREATMENT IN THE PAST?
No
Yes
HAS THE CHILD EVER HAD DENTAL RADIOGRAPHS (X-RAYS) EXPOSED?
No
Yes
HAS THE CHILD EVER SUFFERED ANY INJURIES TO THE MOUTH, HEAD OR TEETH?
No
Yes
HAS THE CHILD HAD ANY PROBLEMS WITH THE ERUPTION OR SHEDDING OF TEETH?
No
Yes
HAS THE CHILD HAD ANY ORTHODONTIC TREATMENT?
No
Yes
WHAT TYPE OF WATER DOES YOUR CHILD DRINK?
Filtered water
Bottled water
Well water
City water
DOES THE CHILD TAKE FLUORIDE SUPPLEMENTS?
No
Yes
IS FLUORIDE TOOTHPASTE USED?
No
Yes
How many times are the child's teeth brushed per day?
When are the teeth brushed?
DOES THE CHILD SUCK HIS/HER THUMB, FINGERS OR PACIFIER?
No
Yes
DOES CHILD PARTICIPATE IN ACTIVE RECREATIONAL ACTIVITIES?
No
Yes
Medical Information
HAS THE CHILD HAD ANY HISTORY OF, OR CONDITIONS RELATED TO, ANY OF THE FOLLOWING:
ANEMIA
No
Yes
BLADDER
No
Yes
MONONUCLEOSIS
No
Yes
CANCER
No
Yes
CHRONIC SINUSITIS
No
Yes
MUMPS
No
Yes
EPILEPSY
No
Yes
HEARING
No
Yes
PREGNANCY (TEENS)
No
Yes
HIV+AIDS
No
Yes
LATEX ALLERGY
No
Yes
RHEUMATIC FEVER
No
Yes
ARTHRITIS
No
Yes
BLEEDING DISORDERS
No
Yes
SEIZURES
No
Yes
CEREBRAL PALSY
No
Yes
DIABETES
No
Yes
SICKLE CELL
No
Yes
FAINTING
No
Yes
HEART
No
Yes
THYROID
No
Yes
IMMUNIZATIONS
No
Yes
LIVER
No
Yes
TOBACCO/DRUG USE
No
Yes
ASTHMA
No
Yes
BONES/JOINTS
No
Yes
TUBERCULOSIS
No
Yes
CHICKEN POX
No
Yes
EAR ACHES
No
Yes
GROWTH PROBLEMS
No
Yes
HEPATITIS
No
Yes
KIDNEY
No
Yes
MEASLES
No
Yes
Other
Name of child's physician
Phone
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
AUTHORIZATION
I certify that I have read and understand the above to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment and examinations rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on my behalf or my dependents.
SIGNATURE OF PARENT/LEGAL GUARDIAN
Date
