Child New Patient Information

Child Registration Form - Dental
* required field

Patient Information

Gender Male Female







Primary Phone Number

Home Cell




Are the patient's immunizations current? Yes No

Responsible Party Information




Parent/Guardian Information

Parent Marital Status Single Married Divorced Widowed Significant Other
Relationship







Phone Number

Home Cell
Secondary Phone Number

Home Cell



Parent 2 Relationship







Phone

Home Cell
Secondary Phone Number

Home Cell


Emergency Contact









Insurance Information


























Dental History



Has your child visited an orthodontist before? Yes No

Has your child's tonsils or adenoids been removed? Yes No
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No
Does your child you have any missing or extra permanent teeth? Yes No
Has your child ever had an injury to (select all that apply): Teeth Mouth Chin
Does your child have speech problems? Yes No
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician? Yes No


Does your child have any allergies/sensitivities to medications or latex? Yes No

Is your child currently taking any prescription or over-the-counter medications? Yes No

Has puberty and/or menstruation begun? Yes No N/A

Has your child ever had a blood transfusion? Yes No

Yes No

Yes No

Yes No
Check if your child has or have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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