Child Patient Form

(562) 430-1013
(714) 828-5951
3551 FLORISTA ST., SUITE 2A
LOS ALAMITOS, CA 90720

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Child Patient Form

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You may fill this form out online and submit it to our secure website (email required), or you can download a blank copy and fill it out before the initial appointment with our doctor.

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Child's Name: Last * First * MI Nickname: Male Female

Birthdate: / / Age: School: Grade:

Child's Home#: ( ) SS#:

Child's Home Address: Street City State Zip

Name: Relation:

Do you have legal custody of this child? Yes No Whom may we Thank for referring you?

Other family members seen by us:

Previous / Present Dentist: Last Visit Date:

Parent's Marital Status: Single Married Divorced Separated Widowed

Step MotherGuardian

Name:

Birthdate: / / Cell#:

Wk#: ( ) Hm#: ( )

Employer: Occupation:

SS#: DL#:

Step FatherGuardian

Name:

Birthdate: / / Cell#:

Wk#: ( ) Hm#: ( )

Employer: Occupation:

SS#: DL#:

Billing:

Name: Last First MI Relation: SS#: DL#:

Billing Address: Street City State Zip

Home#: ( ) Employer: Work#: ( )

Appointments: Maybe we contact you via email? YesNo Email: * Cell#:

Name: Last First MI Hm#: ( ) Wk#: ( )

Best time for Appointments? MTWTHF Time: AMPM

Insurance Co. Name:

Group #: (Plan, Local or Policy#)

Address:

Phone#: ( )

Policy Owner Name:

Relationship to Patient:

Orthodontic Coverage? YES NO

Birthdate: / /

SS#: Employer#:

Insurance Co. Name:

Group #: (Plan, Local or Policy#)

Address:

Phone#: ( )

Policy Owner Name:

Relationship to Patient:

Orthodontic Coverage? YES NO

Birthdate: / /

SS#: Employer#:

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Reason of Visit Today:

Has the Child ever had a serious/difficult problem associated with previous dental work?

YES NO

Is the Child's water fluoridated?

YES NO

Is the Child taking fluoridated supplements?

YES NO

Has the child ever had any pain / tenderness in his/her jaw joint (TM/TMD)?

YES NO

Does the child brush his/her teeth daily?

YES NO

Do you help?

YESNO

Does the child floss his/her teeth daily?

YESNO

Do you help?

YES NO

Child's Physician: Phone: ( ) Last Visit: / /

Is the child currently under the care of a physician?

YES NO

Please list all drugs that the child is currently taking:

Please list all drugs/materials that the child is allergic to:

What do you expect your child's behavior to be? CooperativeFearfulDefiantUnknown

What are your primary concerns about your child's oral health?

Abnormal Bleeding	YESNO	Congenital Heart Defect	YESNO	Hemophilia	YESNO
Allergies to Any Drugs	YESNO	Convulsions / Epilepsy	YESNO	Hepatitis	YESNO
Any Hospital Stays	YESNO	Diabetes	YESNO	HIV+ / AIDS	YESNO
Any Operations	YESNO	Handicaps / Disabilities	YESNO	Kidney / Liver Problems	YESNO
Asthma	YESNO	Hearing Impairment	YESNO	Rheumatic / Scarlet Fever	YESNO
Cancer	YESNO	Heart Murmur	YESNO	Tuberculosis (TB)	YESNO
Please discuss any serious medical problems that the child has had:

Lip Sucking/Biting	YESNO	Nail Biting	YESNO
Nursing Bottle Habits	YESNO	Thumb / Finger Sucking	YESNO

To the best of my Knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the Dental Office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services my child may need, with prior authorization from a parent/legal guardian.

I also authorize the Dental Office to release any information including the diagnosis and records of treatment or examination rendered to my child during the period of such car to third party payers and/or other health practitioners, as is necessary. I authorize and request my insurance company to pay directly to the Dental Office insurance benefits otherwise payable to me. I Understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for paymnet of all services rendered on my behalf or my dependents. In the event of payment default for services previously rendered, I also agree to pay all reasonable collection and/or legal fees incurred in an attempt to collect on this amount.

Signature of Parent or Guardian:____________________________________________________________ Date: ____/____/_____

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