Our Office
Please use our safe and easy form below to allow us to be prepared for your office visit.
Patient Name
Email
Address
City
Home Phone
Work Phone
Sex
Male
Female
Age
Date of Birth
School
Grade
Mother's Name
Mother's Cell
Father's Name
Father's Cell
Whom do we thank for referring you?
Notify in case of emergency?
Relationship with patient?
Primary Insurance Company
Person responsible for account
Birthday
Relationship with patient?
Address
City
Employed by
Business Address
Business City
Business Phone
Contract #
Group #
Subscriber #
Names of other dependants on this plan
List here
Additional Insurance Company
Is the Patient covered by
this additional insurance?
Yes
No
Subscriber Name
Relationship with patient?
Birth date
Address
City
Phone
Employed by
Business Address
Business City
Business Phone
Contract #
Group #
Subscriber #
Names of other dependants on this plan
List here
Medical History
Patient's Physician
Physician phone
Does your child have any health issues?
Yes
No
Has your child ever been hospitalized?
Yes
No
If yes, when and why?
List medications your child is taking,
if any
List drug allergies,
if any
Has your child had any of the following?
Please check all that apply
AIDS/HIV Positive
Hemophilia/Abnormal Bleeding
Anemia
Immunizations current
Asthma
Kidney Disease/Malfunction
Blood Disease
Liver Disease
Cancer
Material Allergies
Chicken Pox
Respiratory Disease
Convulsions/Epilepsy
Rheumatic/Scarlet fever
Cough/Persistent
Shortness of Breath
Cough up Blood
Sinus Problems
Diabetes
Skin Rash
Epilepsy
Spina Bifida
Fainting
Thyroid Disease/Malfunction
Food Allergies
Tonsillitis
Headaches
Tuberculosis
Hearing Impairment
Other
Heart Problems
Describe in detail any of the above items
Dental History
What would you like to do for your child?
Former Dentist
Address
City
Phone
Date of last dental care
Date of last x-rays
How often does your child brush
Does your child experience jaw pain or discomfort?
Yes
No
Ever had a mouth or chin injury?
Yes
No
Does your child have speech problems?
Yes
No
If yes, explain
Has your child ever experienced an adverse
reaction to or in conjunction with a
medical procedure?
Yes
No
Child's habits affecting the mouth or teeth
Thumb sucking
Nail biting
other
Other important information about
your child's dental health
or previous treatments?
I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my child's medical status, I will inform the dentist.
