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)
Soc. Sec #
Hobbies, Sports, etc.
Whom may we thank for referring you?
Relation: Parent/FatherStep ParentGuardian
Same Address as Child: Yes
Relation: Parent/MotherStep ParentGuardian
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.
Is child covered by additional insurance?
Is this the child's first visit to dentist?
Reason for the child's visit today?
Is the child currently in pain?
Does the child require antibiotics before dental treatment?
Has the child ever had a serious/difficult problem associated with previous dental work?
Is the child's water flouridated?
Is the child taking flouride supplement?
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?
Has your child ever experienced a mouth or chin injury?
Does your child have speech problems?
Has your child ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Other information about your child's dental health or previous treatment
Date of last visit
Please describe the child's current physical health.
List medications your child is taking, if any
List drug allergies, if any
Has your child had any serious illnesses or operations?
If yes, please describe
Is your child currently under physician care?
Has your child ever had a blood transfusion?
If yes, please give approximate date
Has your child ever taken Fen-Phen/Redux?
Any hospital stays/operations?
Atopic (allergy prone)
Congenital Heart Disease
Cough up blood
If yes, please describe:
Hemophilia (abnormal bleeding)
High Blood Pressure
Kidney disease or malfunction
Low Blood Pressure
Material allergies (latex, wool, metal, chemicals)
Mitral valve prolapse
Exposed to HIV, but Neg.
Shortness of breath
Thyroid disease or malfunction
Anything you would like to discuss with the doctor in private?
Does/did your child experience any of the following?
Chewing on objects
Nursing bottle habit
Tongue cheek biting
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.