New Patient Heath History Form

Child's Full Name:

Nickname:

Sex

Male Female

Date of Birth:

Age:

Address:

Apt #:

City:

State:

Zip:

Home Phone:

Father's Cell:

Mother's Cell:

Email Address:

Whom may we thank for referring you to our office?

Father's Full Name:

Social Security:

D.O.B:

Employed By:

Occupation:

Address:

Business Phone:

Mother's Full Name:

Social Security:

D.O.B:

Employed By:

Occupation:

Address:

Business Phone:

Marital Status:

Married Widowed Divorced Separated Single

Person Responsible for Child's Account:

Add another sibling

Previous Dentist:

Address:

Date of Last Dental Treatment:

Name of Father's Dental Insurance:

Group #:

Name of Mother's Dental Insurance:

Group #:

HEALTH QUESTIONNAIRE

State condition of child's health:

Has your child ever been under the care of a physician?

Yes No

If yes, state why and when and the name of the physician

Has your child received medication in the past other than antibiotics?

Yes No

If yes, for what?

When?

Has your child received a blood transfusion or blood products?

Yes No

Is your child a carrier of any infectious disease?

Yes No

Is your child adopted?

Yes No

Is your child taking a fluoride vitamin or fluoride tablet?

Yes No

Is your child allergic to penicillin, anesthetic, any medication or food?

Yes No

Has your child had a fluoride put on his or her teeth?

Yes No

Has your child experienced any unfavorable or unpleasant reaction from previous dental or medical care?

Yes No

Has any member of the family ever had an unusual dental history, such as missing or extra teeth?

Yes No

Has there ever been any injury to any of your child's teeth by fall, blow, bump or otherwise?

Yes No

Does your child have a history of osteoporosis or bisphosphonate use?

Yes No

Does your child have any habits such as thumb sucking, nail biting, lip or cheek biting?

Yes No

Please Indicate:

What school does your child attend?

Are there any health or other problems you feel should be brought to the attention of the doctor?

State name of the child's physicians:

Address of the child's physicians:

Phone number of the child's physicians:

I hereby certify the foregoing information is true and correct. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Relationship to Patient:

Date:

CONSENT-RESPONSIBILITY

I authorize the specialist to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with my child. I understand that using anesthetics agents embodies a certain risk. Furthermore, I authorize and consent that the specialist choose and employ such assistance as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for dental services provided in this office to my child, due and payable at the time services are rendered unless other arrangements have been made. In the event payment are not received by the agreed upon dates, I understand that a 1-1/2% finance charge (18% APR) may be added to my account.
I understand that where appropriate, credit bureau reports may be obtained.
I authorize the use of my social security number to file my child's dental claim.

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

Signature:

Date:

Your information will be encrypted.