New Patient Dental/Health Form

1. Tell Us About Your Child

Today's Date

Child's Full Name

Child's Birth Date

Child's Age

Nickname

School

Grade

Child's Home Number

Child's Street Address

Child's Apt No.

Child's City

Child's State

Child's Zip Code

Child's First Language

Child's Second Language

Does your child have any special interests that we should be aware of? (Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.)

Other Siblings Seen By Our Office

2. Who is Accompanying the Child Today?

Name

Relation

Previous Dentist

Phone

Last Visit Date

Parent’s Marital Status

Single Married Widowed Divorced Separated

3. Parent's Information

Add new row

4. Neighbor or Relative Not Living With You

Name

Relation

Phone No.

5. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit No.

City

State

Zip

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Insurance ID No.

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

6. Dual (Secondary) Insurance

Insurance Company Name

7. Health History

If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.

List all drugs your child is currently taking (or write NONE).

List all allergies your child currently has (or write NONE)

Child's Physician

Phone No.

8. Dental History

If no, how long since the last visit to a dentist?

Previous Dentist's Name

Date of Last X-Rays at Previous Dental Visits

If yes, please explain:

Why did you bring your child to the dentist today?

If yes, please explain

I understand that the information I have given is correct to the best of my knowledge and that 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

Date

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