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: ParentStep 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: ParentStep 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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