We are pleased to welcome you and your child to our practice.
Please take a f'ew minutes to f'ill out this form as completely as you can.
If' you have questions we'll be glad to help you. We look forward to working with you in maintaining your child's dental health.

Date

SSH/IC/Patient ID #

Birthdate

Name of Minor/Child

Last Name

First Name

Middle Initial

Sex

Male

Female

Age

Nickname

Hobbies

Cell Phone

Home Address

Street

City

State

Zip

Mailling Address

Street

City

State

Zip

School Name

Phone

Person financially responsible

Home Phone

Work Phone

Whom may we thank for referring you?

Insurance

Father's/Guardians Name

Address (if different from patient's)

Home Phone (if different from above)

Work Phone (if different from above)

Email

Employer

Soc. Sec #

Birthdate

Do you have dental insurance coverage for minor/child?

Yes

No

Plan Name

Phone

Address

Group #

Policy #

Mother's/Guardians Name

Address (if different from patient's)

Home Phone (if different from above)

Work Phone (if different from above)

Email

Employer

Soc. Sec #

Birthdate

Do you have dental insurance coverage for minor/child?

Yes

No

Plan Name

Phone

Address

Group #

Policy #

I your child eligible for treatment under Medical Assistance?

Yes

No

Childs Medical Assistance ID. #

Dental History

Date of last visit to a dentist

For what service

Has child complained about dental problems?

Yes

No

Does child brush teeth daily?

Yes

No

Does child use floss every day?

Yes

No

Is fluoride taken in any form?

Yes

No

Any injuries to mouth, teeth, head?

Yes

No

Any unhappy dental experiences

Yes

No

Any mouth habits - thumbsucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?

Yes

No

Medical History

Minor/Childs Physician

City/State

Phone

Date of last physical examination

Result

Is Minor/Child under care of physician now? .

Yes

No

Receiving any medication or drugs?

Yes

No

Ever been hospitalized?

Yes

No

Ever had surgery?

Yes

No

Is there excessive bleeding when cut?

Yes

No

Medications

Allergies

Has minor/child had any history of or difficulty with any of the following? If yes, please check.

A.I.D.S/H.I.V

Anemia

Asthma

Bladder Problems

Cancer

Cerebral Palsy

Chicken Pox

Convulsions

Diabetes

Drug/Alcohol Abuse

Epilepsy

Fainting

Hearing Problems

Heart Problems

Hepatitis

Kidney Disease

Liver Disease

Measles

Mononucleosis

Mumps

Rheumatic Fever

Sinus Problems

Thyroid Disease

Tuberculosis

Other

Emergency Contact

In the event of an emergency whom should we contact

Name

Relationship

Phone

Name

Relationship

Phone

Authorizations

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.

Minor/Child Consent
I am the parent guardian or personal representative of:

Name of Minor/Child

and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependents is covered by insurance with:

And assign directly to Dr

ll insurance benefits, if any, otherwise payable to me tor services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my minor/child's health care information and may disclose such information to the above-named Insurance Company(ies) and their agents tor the purpose ot obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed

Date

Name of Parent Guardian or Personal Representative

Relationship to Patient

E-Signature

Please sign electronically below.

Patient Information

Insurance

Dental History

Medical History

Emergency Contact

Authorizations

E-Signature