Child Patient Information

Child Registration Form - Dental (1)
* required field

Patient Information

Gender







Parent/Guardian Information





















Emergency Contact









Insurance Information


















Dental History

How did you hear about our Practice?
Why are you seeking dental care for your child today?
Do you have well water at home?
Does your child take Fluoride tablets or vitamins with Fluoride?
Has your child ever had an injury to (select all that apply):
Have your child's tonsils or adenoids been removed?
Does your child have speech problems?
Does your child snore?
Does your child brush his/her own teeth?
Does your child spit toothpaste?
How often do you floss your child's teeth?
Does your child currently suck his/her thumb or other fingers?
Does your child currently use a pacifier?
Does your child currently nurse?
Does your child currently use a bottle?
Does your child currently use a sippy cup?
Has your child been to a dentist before?
Were radiographs (x-rays) taken?

Medical History

Is your child currently being treated by a physician?


Does your child have any allergies or sensitivities?
If yes, please list allergies/sensitivities:
Is your child currently taking any prescription or over-the-counter medications?
Has your child ever had a blood transfusion?
Has your child child had any serious illnesses or operations?
Does your child have, or has she/he had any emotional, mental, or nervous disorders? If yes, please explain:
Check if your child has or has ever had any of the following:
How do you expect your child to behave at today's appointment?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my child's behalf for covered services and payment of any benefits to the office. I understand 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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