Patient and Family Information

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If you would prefer printing out our form and bringing it into our office, please download the two PDF files below. You can then print them and bring them into our office.

PATIENT FORM (PDF)

    PATIENT INFORMATION

    Last
    First
    Middle Initial
    Nickname
    Sex:
    MF
    Birthdate
    Age
    Soc. Sec #
    Address
    Apt #
    City
    State
    Zip
    School
    Grade
    Hobbies, Sports, etc.
    Whom may we thank for referring you?

    PARENTS INFORMATION

    Parent

    Relation: Parent/FatherStep ParentGuardian
    NAME Last
    First
    Middle Initial
    Marital Status
    Same Address as Child: Yes
    Address
    Apt #
    City
    State
    Zip
    Home Phone
    Cell Phone
    Work Phone
    Email
    Soc. Sec #
    Birthdate
    Employer Occupation

    Parent

    Relation: Parent/MotherStep ParentGuardian
    NAME Last
    First
    Middle Initial
    Marital Status
    Same Address as Child: Yes
    Address
    Apt #
    City
    State
    Zip
    Home Phone
    Cell Phone
    Work Phone
    Email
    Soc. Sec #
    Birthdate
    Employer
    Occupation

    DENTAL INSURANCE INFORMATION (Primary Carrier)

    Insurance Name
    Insurance Phone
    Insurance Address
    Insured's Name
    Birthdate
    Soc. Sec #
    Member ID
    Insured's Employer
    I certify that my child is covered by the above insurance co. and I assign all insurance benefit otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover. I hereby authorize that dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
    Name
    Date

    If you have additional dental insurance coverage, complete this for the secondary carrier.

    Is child covered by additional insurance?
    YESNO
    Insurance Name
    Insurance Phone
    Insurance Address
    Insured's Name
    Birthdate
    Soc. Sec #
    Member ID
    Insured's Employer
    I certify that my child is covered by the above insurance co. and I assign all insurance benefit otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover. I hereby authorize that dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
    Name
    Date

    It is important that we know about your child's Medical and Dental History. These facts have a direct bearing on your child's Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

    DENTAL HISTORY

    Is this the child's first visit to dentist? YESNO
    Former Dentist
    Address
    Phone
    Reason for the child's visit today?
    Is the child currently in pain? YESNO
    Does the child require antibiotics before dental treatment? YESNO
    Has the child ever had a serious/difficult problem associated with previous dental work? YESNO
    Is the child's water flouridated? YESNO
    Is the child taking flouride supplement? YESNO
    Does your child get brushed his/her teeth daily?
    Does your child get flossed his/her teeth daily?
    Who brushes and flosses his/her teeth?
    Date of last dental care
    Date of last xrays
    How often does your child floss?
    Does your child experience pain or discomfort in the jaw joint? YESNO
    Has your child ever experienced a mouth or chin injury? YESNO
    Does your child have speech problems? YESNO
    Has your child ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? YESNO
    Other information about your child's dental health or previous treatment

    MEDICAL HISTORY

    Child's Physician
    Phone
    Date of last visit
    Please describe the child's current physical health.
    GoodFairPoor
    List medications your child is taking, if any
    List drug allergies, if any
    Has your child had any serious illnesses or operations? YESNO
    If yes, please describe
    Is your child currently under physician care? YESNO
    If yes, please describe
    Has your child ever had a blood transfusion? YESNO
    If yes, please give approximate date
    Has your child ever taken Fen-Phen/Redux? YESNO

    PLEASE CHECK YES OR NO OF THE FOLLOWING WHICH YOUR CHILD HAS HAD OR PRESENTLY HAS:

    ADD/ADHD YESNO
    AIDS/HIV Pos. YESNO
    Anemia YESNO
    Any hospital stays/operations? YESNO
    Artificial bone/joints/valves YESNO
    Asthma YESNO
    Atopic (allergy prone) YESNO
    Blood Disease YESNO
    Cancer YESNO
    Chicken Pox YESNO
    Congenital Heart Disease YESNO
    Convulsions/epilepsy YESNO
    Cough (persistent) YESNO
    Cough up blood YESNO
    Diabetes YESNO
    Fainting YESNO
    Food allergies YESNO
    Handicapped/disabilities YESNO
    Headaches YESNO
    Hearing Impairment YESNO
    Heart murmur YESNO
    Heart problems YESNO
    If yes, please describe:
    Hemophilia (abnormal bleeding) YESNO
    Hepatitis YESNO
    High Blood Pressure YESNO
    Hives YESNO
    Immunizations current YESNO
    Kidney disease or malfunction YESNO
    Liver disease YESNO
    Low Blood Pressure YESNO
    Lupus YESNO
    Material allergies (latex, wool, metal, chemicals) YESNO
    Measles YESNO
    Mitral valve prolapse YESNO
    Mononucleosis YESNO
    Prosthetics YESNO
    Exposed to HIV, but Neg. YESNO
    Respiratory disease YESNO
    Rheumatic/scarlet fever YESNO
    Shortness of breath YESNO
    Sinus problems YESNO
    Skin rash YESNO
    Spina Bifida YESNO
    Thyroid disease or malfunction YESNO
    Tonsilitis YESNO
    Tuberculosis YESNO
    Anything you would like to discuss with the doctor in private? YESNO
    Does/did your child experience any of the following?
    Breast Fed YESNO
    Chewing on objects YESNO
    Clenching/grinding teeth YESNO
    Lip sucking/biting YESNO
    Mouth breather YESNO
    Nail biting YESNO
    Nursing bottle habit YESNO
    Speech problem YESNO
    Thumb/finger sucking YESNO
    Tongue cheek biting YESNO
    Tongue thrust YESNO
    Used pacifier YESNO
    I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and 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.
    Name
    Date

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