Registration Form

Date

Child's Name

Birthdate

Sex

Male Female

Child's Address

City

State

Zip

E-Mail

Cell Phone

Whom May We Thank For Referring You?

Emergency Name (Other Than Parent)

Phone

Address

City

State

Zip

Parent's Marital Status

Single Married Separated Divorced Other

Father's Name

Birthdate

Father's Employer

Business Address

Bus. Phone

Position

Years Employed

Father's Soc. Sec. No.

Mother's Name

Birthdate

Parent's Dr. Lic. No.

Mother's Employer

Business Address

Phone

Position

Years Employed

Mother's Soc. Sec. No.

PERSON RESPONSIBLE FOR THIS ACCOUNT

Father Mother Guardian

If guardian, please indicate name

Address (lf Dif. Than Above)

City

State

Zip

Years At This Address

Phone

FOR PATlENTS COVERED BY DENTAL INSURANCE

Subscriber ls

Father Mother Guardian

If guardian, please indicate name

lnsurance Company

Group No.

If Covered By More Than One Plan, Fill Out Next Section

Subscriber is

Father Mother Guardian

If guardian, please indicate name

lnsurance Company

Group No.

Deductible

Max Benefit

Benefit Year Starts

Please choose the appropriate answer

1 . Does your child have a health problem?

Yes No

2. Was your child a patient in a hospital?

Yes No

3. Date of last physical exam

4. ls your child now under medical care?

Yes No

5. ls your child taking medication now?

Yes No

6. Has your child ever had a serious illness or operation?

Yes No

7. If yes on #6, please explain

8. Does your child have (or ever had) any of the following disease?

a. Rheumatic Fever or Heart Murmur

Yes No

b. Congenital heart disease

Yes No

c. Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arterioscierosis, stroke)

Yes No

d. Allergy?

Food Medicine Other

e. Do you have (or had)

Asthma Hay Fever

f . Hives or a skin rash

Yes No

g. Fainting spells or seizures

Yes No

h. Hepatitis, jaundice or liver disease

Yes No

i. Diabetes

Yes No

j. lnflammatory rheumatism (painful or swollen joints)

Yes No

k. Arthritis

Yes No

l. Stomach ulcers

Yes No

m. Kidney trouble

Yes No

n. Tuberculosis (TB)

Yes No

o. Persistent cough or cough up blood

Yes No

p. Veneral disease

Yes No

q. Epilepsy

Yes No

r. Sickle Cell disease

Yes No

s. Thyroid disease

Yes No

t. AIDS

Yes no

u. Emphysema

Yes No

v. Psychiatric treatment

Yes No

w. Cleft lip/ palate

Yes No

x. Cerebral palsy

Yes No

y. Mental retardation

Yes No

z. Hearing disability

Yes No

aa. Developmental disability

Yes No

if yes, explain

bb. Was your child premature?

Yes No

If yes, how many weeks?

cc. Other

9. Does your child have to urinate (pass water) more than six times a day?

Yes No

10. ls your child thirsty much of the time?

Yes No

11. Has your child had abnormal bleeding associated with previous surgery extractions or accidents?

Yes No

12. Does he/ she bruise easily?

Yes No

13. Has he / she ever required a blood translusion?

Yes No

14. Does he / she have any blood disorders such as anemia, etc?

Yes No

15. Has he / she ever had surgery, x-ray or chemotherapy for a tumor, growth or other condition?

Yes No

16. Does your child have a disability that prevents treatment in a dental office?

Yes No

17. ls he / she taking any of the following?

a. Antibiotics or sulfa drugs

Yes No

b. Anticoagulants (blood thinners)

Yes No

c. Medicine or high blood pressure

Yes No

d. Cortisone or steroids

Yes No

e. Tranquilizers

Yes No

f. Aspirin

Yes No

g. Dilantin or other anticonvulsant

Yes No

h. lnsulin, tolbutamide, orinase, orsim

Yes No

i. Any other?

18. ls he/she allergic to, or has he/she ever reacted adversely to any of the following?

a. Local anesthetics

Yes No

b. Penicillin or other antibiotics

Yes No

c. Sulfa drugs

Yes No

d. Barbituates, sedatives, or sleeping pills

Yes No

e. Aspirin

Yes No

f. Any other?

19. Has he/she any serious trouble associated with any previous dental treatment?

Yes No

If so, please explain

20. Are you interested in sealants for your child?

Yes No

21 . Last date of dental examination

22. Has he/she ever had orthodontic treatment (worn braces)?

Yes No

23. Has he/she ever been treated for any gum disease (gingivitis, periodontitis, trenchmouth, pyorrhea)?

Yes No

24. Does his/her gums bleed when brushing teeth?

Yes No

25. Does he/she grind or clench teeth?

Yes No

26. Has he/she often had toothaches?

Yes No

27 . Has he/she had frequent sores in his/her mouth?

Yes No

28. Has he/she had any injuries to his/her mouth or jaws?

Yes No

29. Does he/she have any sores or swellings of his/her mouth or jaws?

Yes No

30. Have you been dissatisfied with your child's previous dental care?

Yes No

ADOLESCENT WOMEN

31 . Are you pregnant now, or think you may be?

Yes No

32. Do you anticipate becoming pregnant?

Yes No

33. Are you taking the pill?

Yes No

Please add anything you feel is important for the doctor to know

To the best of my knowledge, all of the preceding answers are true and correct. lf I ever have any change in my health, or if my medicines change, I will inform the dentist at the start of the next appointment.

Also, the undersigned hereby authorizes the taking of x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs (after discussing these with the patient). I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand the office may request information from, or report information to a credit rating institution.

Patient (or guardian's) signature

Date

FOR OFFICE USE ONLY

History Reviewed and/or Updated

Date

By Whom

premed

no premed

History Reviewed and/or Updated

Date

By Whom

premed

no premed

History Reviewed and/or Updated

Date

By Whom

premed

no premed

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Registration Form - Child

PERSON RESPONSIBLE FOR THIS ACCOUNT

FOR PATlENTS COVERED BY DENTAL INSURANCE

Please choose the appropriate answer

FOR OFFICE USE ONLY