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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