Child New Patient Paperwork

1. Tell Us About Your Child

Today's Date

Child's Last Name

First Name

Nickname

Child's Birthdate

Child's Age

School

Grade

Child's Home #

Social Security Number

Child's Home Address

Apt / Condo #

State

Zip

Home #

E-mail Address

2. Who Is Accompanying The Child Today?

Name

Relation

Do you have legal custody of this child?

Yes No

Whom may we Thank for referring you?

Other family members seen by us:

Previous / Present Dentist

Last Visit Date

3. Mother's Information

Step Mother

Guardian

Name

Birthdate

Work #

Ext

Home #

Employer #

SS #

DL #

Father's Information

Step Father

Guardian

Name

Birthdate

Work #

Ext

Home #

Employer #

SS #

DL #

4. Person Responsible For Account

Name

Relation

Billing Address

City

State

Zip

Work #

Ext

Home #

Employer

DL #

SS #

Who is responsible for making appointments?

Name

Work #

Ext

Home #

5. Primary Dental Insurance

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

ID #

Policy Owner's Employer

Orthodontic Coverage?

Yes No

Secondary Dental Insurance

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

ID #

Policy Owner's Employer

Orthodontic Coverage?

Yes No

6. Why did you bring the child to the dentist today?

Has the child ever had a serious / difficult problem associated with previous dental work?

Yes No

Is the child's water fluoridated?

Yes No

Is the child taking fluoridated supplements?

Yes No

Has the child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

Yes No

Does the child brush his / her teeth daily?

Yes No

Floss his / her teeth daily?

Yes No

Child's Physician

Phone #

Date of Last Visit

Is the child currently under the care of a physician?

Yes No

Please describe the child's current physical health

Good Fair Poor

Has the child ever taken Phen-Fen?

Good Fair Poor

(Also known as Redux or Pondimin) If so, when?

Please list all prescription / over the counter or herbal supplement drugs that the child is currently taking

Aside from Hems below, list all drugs/materials mat the child is allergic to

Latex

Yes No

Metal / Nickel

Yes No

Plastic

Yes No

7. Has the child ever had any of the following medical problems?

Abnormal Bleeding

Yes No

ADD / ADHD

Yes No

Any Hospital Stays

Yes No

Any Operations

Yes No

Artificial Bones / Joints

Yes No

Asthma

Yes No

Cancer

Yes No

Congenital Heart Defect

Yes No

Convulsions / Epilepsy

Yes No

Diabetes

Yes No

Handicaps / Disabilities

Yes No

Hearing Impairment

Yes No

Heart Murmur

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

HIV + / AIDS

Yes No

Kidney / Liver Problems

Yes No

Rheumatic / Scarlet Fever

Yes No

Sickle Cell Disease / Traits

Yes No

Tuberculosis (TB)

Yes No

Please discuss any serious medical problems that the child has had

8. Does the child have any of the following habits?

Lip Sucking / Biting

Yes No

Nail Biting

Yes No

Nursing Bottle Habits

Yes No

Thumb / Finger Sucking

Yes No

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA

I understand that the information that I have given 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 authorize the dental staff to perform the necessary dental services my child may need.

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 or guardian

Date

The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved.

OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the parent / guardian & patient named herein.

Initials

Date

Doctor's Comments

MEDICAL HISTORY UPDATE

Add new row

Change of Appointment Policy

We require a 48-hour notice for a scheduled appointment change.
Please be courteous, a fee will be a charge for any change in appointment without 48 hours notice. This is not payable by your insurance.

I have read and fully understand my financial responsibilities under this policy.

Patient / Guarantor Signature

Date

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