Required fields are in *Bold

Patient Information

Today's date:

Patient name:

Sex: Male Female

Date of birth:

Street address:

Apt/Unit:

City/State/Zip

Responsible party:

Responsible party phone numbers:

Who referred you?

Would you like an appointment confirmation text and email?
YesNo

If yes, to whom should we send it?

Dental Insurance

Father/Guardian name:

Birth date:

SSN #:

Address (if different from patient's):

Phone numbers:

Email:

Do you have dental insurance/coverage for this child?
YesNo

If yes, is it primary or secondary?

Insurance Co. Name & Phone #

Insurance Co. Address:

Group # and ID#:

Mother/Guardian name:

Birth date:

SSN #:

Address:

Phone numbers:

Email:

Do you have dental insurance/coverage for this child?
YesNo

If yes, is it primary or secondary?

Insurance Co. Name & Phone #

Insurance Co. Address:

Group # and ID#:

Dental History

Date of last visit:

For what service?

Any oral habits such as mouth breathing, pacifier, thumbsucking, sleeping with a bottle, nail biting?

Does child brush teeth daily?
YesNo

Does child floss daily?
YesNo

Is fluoride taken in any form?
YesNo

Has child complained about dental problems?
YesNo

Any injuries to mouth, teeth, head?
YesNo

Any unhappy dental experiences?
YesNo

Medical History

Child's Physician:

Date of last physical exam:

Results:

Is child under the care of a physician now?
YesNo

Ever been hospitalized?
YesNo

Ever had surgery?
YesNo

Excessive bleeding when cut?
YesNo

Medications:

Allergies:

Other:

Signature