First Name Middle Initials Last Name Preferred Name Nickname (if any): Date of Birth (MM/DD/YYYY): Age: Sex: Attends what School? Brothers and Sisters (Names and Age): Pets (Kind and Name)/Hobbies: Shows like to watch?
Why did you make this appointment? Is this your child’s first visit to the dentist? Yes No If not, how long since the last dental visit? Child’s previous dentist name and address: Approximate date of last dental “x-rays”: Does your child currently have any dental problems or has your child ever had any major dental problems in the past? Yes No If so, please explain: Has your child had any injury to the teeth, mouth or jaw? Yes No Does your child have any jaw joint clicking, locking or pain? Yes No
Does your child receive fluoride daily? Yes No We have fluoride in our water supply. Yes No Child swallows a fluoride supplement daily. Yes No Does your child use a toothpaste containing fluoride? Yes No Does your child use a fluoride mouthwash at home? Yes No Does your child receive a fluoride mouthwash at school? Yes No How often are your child’s teeth brushed? 1x/day 2x/day 3x/day Is your child familiar with dental floss? Yes No We use floss: Daily Occasionally Never
Have you ever been advised that your child has a “bite problem?” Yes No Does your child have any oral habits such as thumb, lip or finger sucking, apcifier, nailbiting, clenching or grinding teeth, etc? Yes No Does your child have a speech problem of which you are aware? Yes No
Child’s Physician name, address, and phone number: Does your child have regular medical exams? Yes No Is your child currently under a physician’s care for any reason? Yes No Has your child had any surgery, serious illness, or accident in the past? Yes No If so, please explain:
Has your child had any history of:
Heart trouble/Murmur Yes No Rheumatic Fever Yes No Asthma/Cystic Fibrosis Yes No Diabetes Yes No Kidney or Liver Disease/Hepatitis Yes No Epilepsy or nervous system disorder Yes No Fainting/Seizures Yes No Tuberculosis Yes No Joint Replacement or Implant Yes No Bleeding trouble/Anemia/Hemophilia Yes No Tumor or Cancer Yes No HIV infection or AIDS Yes No Tobacco Use Yes No Eating Disorder Yes No Does your child have any mental, emotional, or physical disabilities? Yes No If so, please explain: Is your child taking any medications? Yes No If so, please list: Does your child have any allergies? Yes No Medication Latex Yes No Metals Yes No Foods Other Are your child’s immunizations up to date? Yes No
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.
Permission is hereby granted to the doctor to perform any necessary dental treatments for this child after doctor’s consultation with the parent or presenting adult.
I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.
I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
Signature of patient, parent, or guardian: Relationship to Patient:
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