Patient Information

Child Patient Registration & Medical History
Child's Name *

First Name Last Name
Gender *

Male Female
Birth Date *

Month Day Year
Contact Information - Mother
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year
E-mail
Cell Number

- Area Code Phone Number
Home Number

- Area Code Phone Number
Work Number

- Area Code Phone Number
extension
Employer
Occupation
Contact Information - Father
Full Name

First Name Last Name
Same address as above

Address if different

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year
E-mail
Cell Number

- Area Code Phone Number
Home Number

- Area Code Phone Number
Work Number

- Area Code Phone Number
extension
Employer
Occupation
Primary DENTAL Insurance
Does Child Have Dental Insurance? *

Yes No
Policy Owner Name

First Name Last Name
Policy Owner Birthdate

Month Day Year
Relationship to Patient
Policy Owner Employer
Insurance Company
Group ID # (Required if using dental insurance)
Policy Owner ID # or Soc. Sec. # (Required if using dental insurance)
Insurance Phone (required)

- Area Code Phone Number
Secondary DENTAL Insurance (if applicable)
Does Child Have a Secondary Dental Insurance? *

Yes No
Policy Owner Name

First Name Last Name
Policy Owner Birth Date

Month Day Year
Relationship to Patient
Policy Owner Employer
Insurance Company
Group ID # (Required if using dental insurance)
Policy Owner IS # or Soc. Sec. # (Required if using dental insurance)
Insurance Phone

- Area Code Phone Number
Dental History
Reason for seeking Dental Care at this time? *
Date of Last Dental Visit?
Reason?
Date of Last Dental X-rays?
Former Dentist or Current DDS if Visiting?
City, ST
How often does child BRUSH? *

Once a day Twice a day Three times a day
How often does child FLOSS? *

1 2 3
Flossing Continued *

Day Week Month
How does child feel about dental treatment? *

Relaxed A little uneasy Anxious Tense
Has child ever had Nitrous Oxide (laughing gas) during dental treatment? *

No Yes
Has child ever been requested to take antibiotics or other medications before a dental appointment? *

No Yes

Does/Has child ever had any of the following? *

	Check All That Apply
Aching/Sensitive
Bleeding Gums
Grinding/Clenching
Cold Sores
Broken Filling
Loose Teeth
Bad Breath
Dry Mouth
Areas of Food Traps
Difficulty Opening
Gum Infection
Oral Surgery
Clicking/Popping Jaw
Jaw Pain
Orthodontics
Periodontal Treatment
None

Please indicate any dental concerns: *

	Check All That Apply
Close gaps between teeth
Straighten or "even out" front teeth
Replace old fillings
Whiten teeth
Change shape of teeth
Make teeth same color
Replace missing teeth
Other
None

Medical History
Physician's Name
Is child currently under a physician's care? *

No Yes
If so, for what reason?

Check the conditions to indicate if child has or has had any of the following: *

	Check All That Apply
Artificial Heart Valve
Heart Disease
Heart Murmur
Mitral Valve Prolapse
Pacemaker
Heart Surgery
Rheumatic/Scarlet Fever
Artificial Joint
Hepatitis A, B, C
Liver Disease
Kidney Disease
HIV or AIDS
Herpes
High Blood Pressure
Stroke
Cancer
Chemotherapy
Radiation Therapy
Glaucoma
Asthma
Sinus Trouble
Tuberculosis
Diabetes
Epilepsy or Seizures
Fainting/Dizzy Spells
Psychiatric Treatment
Chemical Dependency
Bleeding Problems
Circulatory Problems
Headaches
Back Problems
None of the above

Medications / Allergies
Is child currently taking any medications? *

No Yes
Please list drugs, medications or injections taken in the last 3 months.

List Allergies: *

	Check All That Apply
Aspirin
Codeine
Latex
Penicillin
Sulfa
None

List Any Other Allergies:
Would you like to speak to the Doctor privately about any concerns? *
How Did You Hear About Our Office? *

Yelp Search (Reviews) Google Search (Reviews) Media Ad Other
I (parent/guardian) understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and authorize payment of any insurance benefits to the office.

I understand financial arrangements must be made in advance. I am personally responsible for payment of all fees for dental services in this office regardless of insurance coverage. Payment is due when services are rendered. All emergency services or any dental service performed without prior financial arrangements must be paid for at the time services are performed.
Acceptance of Terms *

I have read the above conditions and agree to their content.
Parent/Guardian Initials *
Doctor Only: I verbally reviewed medical history information above with patient's guardian.

_______________________________________________________________________________

Doctor Signature
Today's Date

- Month - Day Year
at
: Hour Minutes
Should be Empty:

Child Patient Registration & Medical History

Contact Information - Mother

Contact Information - Father

Primary DENTAL Insurance

Secondary DENTAL Insurance (if applicable)

Dental History

Medical History

Medications / Allergies