Your Name (required) Your Email (required) Tell Us About Your Child Child's Last Name: Child's First Name: Child's MI: Nickname: Gender: MaleFemale Birth Date: Age: School: Grade: Child's Home #: SS#: Child's Home Address: City: State: Zip Code: Who is accompanying the child today? Name: Relation: Do you have legal custody of this child? YesNo Whom may we thank for referring you? Other family members seen by us: Previous / Present Dentist: Last Visit Date: Marital Status: MarriedSingleWidowedDivorcedSeperated Mother of Child Father of Child Name: Name: Birthdate: Birthdate: Cell Ph: Cell Ph: Hm Ph: Hm Ph: Wk Ph: Wk Ph: Employer: Employer: Email: Email: SS#: SS#: DL#: DL#: Person responsible for account Billing: Last Name: First Name: MI: Relation: Billing Address: City: State: Zip Code: Home Ph: Employer: Work #: Appointments: Last Name: First Name: MI: Hm #: Work #: Primary Dental Insurance Secondary Dental Insurance Insurance Co. Name: Insurance Co. Name: Group # (Plan,Local, or Policy #): Group # (Plan,Local, or Policy #): Address: Address: Phone #: Phone #: Policy Owner Name: &Policy Owner Name: Relationship to Patient: Relationship to Patient: Birthdate: Birthdate: SS#: SS#: Employer: Employer: What is the primary reason for the child’s appointment? Reason for first visit: Child's Interests, Hobbies: Has the child ever had a serious/difficult problem associated with previous dental treatment? YesNo Is the child's water fluoridated? YesNo Is the child taking fluoridated supplements? YesNo Has the child ever had any pain/tenderness in his/her jawjoint (TMJ/TMD)? YesNo Does the child have headaches, neck pain or balance problems? YesNo Does the child brush his/her teeth daily? YesNo Does the child floss (or someone) his/her teeth daily? YesNo Child's Physician: Phone: Last Visit: Is the child currently under the care of a physician? YesNo Please describe the child's current physical health: GoodFairPoor Please list all drugs that the child is currently taking: Please list all drugs/materials that the child is allergic to: Has the child ever had any of the following medical problems? Abnormal Bleeding YesNo Congenital Heart Defect YesNo Hemophilia YesNo Drug Allergies YesNo Convulsions/Epilepsy YesNo Hepatitis YesNo Any Hospital Stays YesNo Diabetes YesNo HIV+/AIDS YesNo Any Operations YesNo Handicaps/Disabilities YesNo Kidney/Liver YesNo Asthma YesNo Hearing Impairment YesNo Rheumatic/Scarlet Fever YesNo Cancer YesNo Heart Murmur YesNo Tuberculosis YesNo Please discuss any serious medical problems that the child has had: Has the child ever had any of the following medical problems? Lip Sucking/Biting YesNo Nail Biting YesNo Nursing Bottle Habits YesNo Thumb/Finger Sucking YesNo Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of 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. The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved. Signature of Parent or Guardian: Sign your name below (using your mouse or finger) Date: After you hit the "Send" button to submit this form, you will see a confirmation below that the form has been sent. Then click the "Next" button to continue to the next form.