Child Form

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Parent 1

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Parent 2

Name:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

Have we treated any other family members? Yes No

Name:

Have 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 have speech problems? Yes No

If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

Medical History

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

Reason:

Physician:

Last Visit:

Phone:

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

If yes, please list:

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

If yes, please list with the dosage:

Has puberty and/or menstruation begun? Yes No NA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion? Yes No

If yes, give approximate dates:

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 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 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.

Submitted by:

Date: