Child Patient Form

Child Patient Form

Fill out the form below to submit it online to our secure website. You can also download a copy of the form to fill and out bring with you to your child's appointment with the doctor.

  Download Form

* REQUIRED FIELDS

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 Father Guardian
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: Person coordinating appointments Name:  Last First     
MI   Hm#: ( )     Wk#: ( )      Cell#:  Email:  * 
Best time for Appointments?  TH F    Time:      AM PM
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 (TMJ)? YES  NO
Does the child brush his/her teeth daily? YES  NO Do you help?
YES  NO
Does the child floss his/her teeth daily? YES NO 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? Cooperative Fearful Defiant Unknown
What are your primary concerns about your child's oral health?
Abnormal Bleeding YESNO Congenital Heart Defect YESNO Autism YESNO
Allergies to Any Drugs YESNO Convulsions / Epilepsy YESNO Hepatitis YESNO
Any Hospital Stays YESNO Diabetes YESNO ADD/ADHD 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:
Pacifier Habit 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 care 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 payment 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: ____/____/_____