Child New Patient Form Step 1 of 6 16% Tell Us About Your ChildToday's Date MM slash DD slash YYYY Child's Name First Middle Initial Last NicknameGender Male Female Child's BirthdateChild's AgeChild's Home NumberChild's Email AddressChild's Home Address Street Address Address Line 2 City State ZIP / Postal Code Who Is Accompanying The Child Today?NameRelationWhom may we thank for referring you?Previous / Present DentistLast Visit Date Mother's InformationRelation To Child Biological Mother Stepmother Guardian NameBirthdateEmail AddressHome Phone NumberCell Phone NumberFather's InfoRelation To Child Biological Father Stepmother Guardian NameBirthdateEmail AddressHome Phone NumberCell Phone Number Insurance - PrimaryInsurance Company NameInsurance Company AddressGroup Number (Plan, Local or Policy Number)Policy Owner's NameRelation to PatientPolicy Owner's BirthdateID NumberPolicy Owner's EmployerEmployer's AddressOrthodontic Coverage? Yes No Insurance - SecondaryDental Coverage? Yes No Insurance Company NameInsurance Company AddressInsurance Company Phone NumberGroup Number (Plan, Local or Policy Number)Policy Owner's NameRelation to PatientPolicy Owner's BirthdateID NumberPolicy Owner's EmployerEmployer's AddressOrthodontic Coverage? Yes No Child's Dental HistoryWhy did you bring the child to the dentist 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 / TMD)? Yes No Does the child brush his/her teeth daily? Yes No Floss his/her teeth daily? Yes No Child's PhysicianPhone NumberDate of last visitIs the child currently under the care of a physician? Yes No Please describe the child's current physical health Good Fair Poor Has the child ever taken Fosamax, or any other bisphosphonate? Yes No Has the child ever taken Phen-Fen? Yes No Please list all drugs that the child is currently takingPlease list all drugs / materials that the child is allergic toLatex? Yes No Metals/Nickel? Yes No Plastic? Yes No Child's Medical HistoryHave the child ever had any of the following medical problems Abnormal Bleeding Diabetes ADD/ADHD Handicaps/Disabilities Allergies to any drugs Hearing Impairment Any Hospital Stays Heart Murmur Any Operations Hemophilia Artificial Bones/Joins/Valves Hepatitis Asthma HIV+ / AIDS Cancer Kidney / Liver Problems Congenital Heart Defect Rheumatic / Scarlet Fever Convulsions / Epilepsy Sickle Cell Disease / Traits Tuberculosis (TB) Please list any serious medical problems that the child has hadDoes / did the child have any of the following habits? Lip Sucking / Biting Nursing Bottle Habits Nail Biting Thumb / Finger Sucking Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.Emergency ContactNameRelationPhone NumberI 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.(Required)Please sign above.
