Child Patient Form

Please correct the errors described below.

Child's Name

Birth Date

Nickname

School

Hobbies

Who is accompanying the child today?

Relationship to child

Reason for today's visit?

Last Dental Visit?

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

Is the child currently under the care of a physician?

Child’s Physician

Phone Number

Date of Last Visit

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to my personal cell phone.

Yes No

Please list current medications child is taking

List all drug allergies

Does/ did the child have any of the following habits?

Breast fed

Chewing on objects

Clenching/grinding teeth

Lip sucking/biting

Mouth breather

Nail biting

Nursing bottle habits

Speech problems

Thumb/finger sucking

Tongue/cheek biting

Tongue Thrust

Used pacifier

Please describe the child’s current physical health.

Is the child currently in pain?

Does the child require antibiotics before dental treatment?

Is the child taking fluoridated supplements?

Has the child ever had any pain/tenderness in his/her jaw joints?

Does the child brush his/her teeth daily?

Floss his/her teeth daily?

Has he/she been to an orthodontist?

I affirm that the information I have given is correct to the best of my knowledge. It will be held in strictest confidence.
I authorize the dental staff to perform the necessary dental services my child may need.

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 of parent or guardian

Date

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Electronic signature

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