Patient Information Child's Name Last Name First Name Initial Soc. Sec. # Address City State Zip Home Phone Cell Phone Email Birthdate Age Sex MF School Grade Hobbies/Sports Whom may we thank for referring you? Notify in case of emergency Emergency Home Phone Emergency Cell Phone Business Phone Business Email Primary Insurance Person Responsible for Account Last Name First Name Initial Relation to Child Birthdate Soc. Sec. # Address (if different from child) City State Zip Home Phone Cell Phone Email Occupation Employer Business Address Business Phone Business Email Insurance Company Insurance Phone Insurance Email Contract # Group # Subscriber # Name of other dependents under this plan Additional Insurance Is child covered by additional insurance? YesNo Subscriber Name Relation to Child Birthdate Address (if different from child) City State Zip Home Phone Soc. Sec. # Subscriber Employed by Business Phone Business Email Insurance Company Insurance Phone Insurance Email Contract # Group # Subscriber # Name of other dependents under this plan Dental History What would you like us to do for your child today? Former Dentist Address Phone Date of last dental care Date of last x-rays How often does your child brush? 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 Has your child had any serious illnesses or operations? YesNo If yes, describe: Is your child currently under physician care? YesNo If yes, describe: Has your child ever had a blood transfusion? YesNo If yes, give approximate dates: Has your child ever taken Fen-Phen/Redux? YesNo Check (✓) if your child has had any of the following: AIDS/HIV PositiveCough up bloodHemophilia/Abnormal bleedingShortness of breathAnemiaAsthmaAtopic (allergy prone)Blood diseaseCancerChicken PoxConvulsions/EpilepsyCough, persistentDiabetesEpilepsyFaintingFood allergiesHeadachesHearing Impairment Heart problems Hemophilia/Abnormal bleedingImmunizations currentKidney disease or malfunctionLiver diseaseMaterial allergies (latex, wool, metal, chemicals)Respiratory diseaseRheumatic/Scarlet feverShortness of breathSinus problemsSkin rashSpina BifidaThyroid disease or malfunctionTonsillitisTuberculosis Other List medications your child is taking, if any: List drug allergies, if any: AUTHORIZATION I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my child's medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. Signature Date Payment is due in full at time of treatment, unless prior arrangements have been approved.
