Child Patient Information

Date

SS/HIC/Patient ID #

Birthdate

Name of Minor / Child

Age

Nick Name

Hobbies

Phone

Home Address

Mailing Address

School Name

School Phone

Person Financially Responsible

Home Phone

Work Phone

Who may we thank for referring you?

Father's / Guardian's Name

Address (if different from patient's)

Home Phone

Work Phone

Email address

Employer

Soc. Sec. #

Birthdate

Plan Name

Phone

Address

Group #

Policy #

Mother's / Guardian's Name

Address (if different from patient's)

Home Phone

Work Phone

Email address

Employer

Soc. Sec. #

Birthdate

Plan Name

Phone

Address

Group #

Policy #

Is your child eligible for treatment under Medical Assistance?

Yes No

Child's Medical Assistance ID #

Date of last visit to a dentist

For what service

Has child complained about dental problems?

Yes No

Is fluoride taken in any form?

Yes No

Does child brush teeth daily?

Yes No

Any injuries to mouth, teeth, head?

Yes No

Does child use floss every day?

Yes No

Any unhappy dental experiences?

Yes No

Any mouth habits - thumbsucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?

Yes No

Minor / Child's Physician

City / State

Phone

Date of last physical examination

Results

Is Minor/Child under care of physician now?

Yes No

Receiving any medication or drugs?

Yes No

Ever been hospitalized?

Yes No

Ever had surgery?

Yes No

Is there excessive bleeding when cut?

Yes No

Medications

Allergies

If other, Please specify

In the event of an emergency, whom should we contact?

Name

Relationship

Phone

Name

Relationship

Phone

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.

Minor/Child Consent

I am the parent, guardian, or personal representative of

and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my minor/child's health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent, Guardian or Personal Representative

Relationship to Patient

Date

TO BE COMPLETED AT LATER VISIT

Has there been any change in patient's health since last dental appointment?

Yes No

If yes, please describe

Is patient taking any new medications?

Yes No

If yes, please list

Parent/Guardian Signature

Date

Dentist Signature

Date

Acknowledgement of Receipt of Notice of Privacy Practices

You may refuse to Sign This Acknowledgement

have received a copy of this office's Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

If other, Please specify

Your information will be encrypted.