Welcome!
We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward to working with you in maintaining your child's dental health.
Patient Information
Name of Minor/Child
Sex
Home Address
Insurance
(if different from above)
(if different from above)
Do you have dental insurance coverage for minor/child?
(if different from above)
(if different from above)
Do you have dental insurance coverage for minor/child?
Is your child eligible for treatment under Medical Assistance?
Dental History
Has child complained about dental problems?
Does child brush teeth daily?
Does child use floss every day?
Is fluoride taken in any form?
Any injuries to mouth, teeth or head?
Any unhappy dental experiences?
Any mouth habits i.e. thumb sucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?
Medical History
Is Minor/Child under care of physician now?
Receiving any medication or drugs?
Ever been hospitalized?
Ever had surgery?
Is there excessive bleeding when cut?

HAS MINOR/CHILD HAD ANY HISTORY OF OR DIFFICULTY WITH ANY OF THE FOLLOWING? IF YES, PLEASE CHECK

Emergency Contact

In the event of an emergency, whom should we contact?

Authorizations

The information that I have given is correct to the best of my knowledge. I understand 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 for my minor/child.

I certify that my minor/child is covered by insurance with, and assign directly to all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Update

(To be completed at a later visit)

Has there been any change in patient's health since last dental appointment?
Is patient taking any new medications?