Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential. Step 1 of 10 10% Tell Us About Your ChildToday's Date* Child's Full Name*NicknameGender*MaleFemaleChild's Birthdate* Child's Age*SchoolSiblings We TreatHow Did You Hear About Kids Healthy Teeth?* Search Engine (Google/Yahoo/Bing) Friend/Family/Co-worker Social Media (Facebook/Twitter/Google+) Yelp Insurance Other Does your child have any special interests that we should be aware of?(Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.) Child's Home AddressStreet Address*Apt #City*State*Zip Code*Child's Home Number Parent or Legal Guardian's InformationThe information in this section applies to the main legal caregiver of the child / children.Name*Relationship to Child*Birthdate* Marital StatusSingleMarriedDivorcedWidowedParent or Legal Guardian's Home AddressStreet Address*Apt #City*State*Zip Code*EmployerWork NumberHome Number*Cell NumberSocial Security Number*Driver's License NumberEmail Address* Spouse or Other Legal Guardian's Information(If different from #2 above)Name*Relationship to Child*Birthdate* Marital StatusSingleMarriedDivorcedWidowedSpouse or Other Legal Guardian's Home AddressStreet Address*Apt #City*State*Zip Code*EmployerWork NumberHome Number*Cell NumberSocial Security Number*Driver's License NumberEmail Address* How Did You Learn About Our Practice?How Did You Learn About Our Practice? Who Will Be Accompanying the Child/Children to Their Appointment?Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.Name*Relationship*Do you have legal custody of this child?*YesNo Primary Dental InsuranceInsurance Company NameInsurance Co. AddressUnit #CityStateZip CodeInsurance Co. PhoneGroup # (Plan, Local or Policy #)Insurance ID #Policy Owner's NameRelationship to PatientPolicy Owner's Birthdate Policy Owner's SSNPolicy Owner's Employer Dual (Secondary) InsuranceDo you have dual (secondary) insurance?YesNoInsurance Company Name Dental HistoryIs this your child's first visit to a dentist?*YesNoIf no, how long since the last visit to a dentist?Previous Dentist's NameDate of Last X-Rays at Previous Dental VisitsHave there been any injuries to the teeth, face or mouth?*YesNoIf yes, please explain:Why did you bring your child to the dentist today?Does your child have any of the following habits? Lip Sucking / Biting Tongue Thrust and Pacifier Use Nursing / Bottle Habits Nail Biting Thumb / Finger Sucking Tobacco Use Does your child have any current dental issues? Cavities Toothache Bleeding Gums Discolored Teeth Bad Breath Teeth Grinding Mouth Trauma/Broken Tooth Sensitivity to Hot/Cold Has your child ever had a serious or difficult problem associated with previous dental work?YesNoIf yes, please explain:Is your child's water fluoridated?YesNoDoes your child brush his/her teeth daily?YesNoIs your child taking fluoride supplements?YesNoDoes your child floss his/her teeth daily?YesNoHas your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?YesNo Social HistoryChild's First Language*Child's Second LanguageHealth HistoryHas your child ever had any of the following conditions?* Abnormal Bleeding Auto Immune Disease Developmental Delays/Disabilities Kidney/Liver Conditions ADD/ADHD Asthma Diabetes Pregnancy Allergies to Any Drugs Autism Spectrum Disorder Hearing Impairment Reflux/GI Problems Allergies to Latex Products Cancer Hemophilia/Blood Disorders Rheumatic/Scarlet Fever Any Hospital Stays Cardiac (Heart Conditions) Hepatitis Convulsions/Seizure Disorder Any Operations Congenital Birth Defects HIV + / AIDS Tuberculosis None of the Above If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.List all drugs your child is currently taking (or write NONE).*List all allergies your child currently has (or write NONE).*Child's Physician*Phone NumberIs your child currently under the care of a physician?*YesNoDescribe your child's current physical health.*GoodFairPoor SignatureI understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.Signature of Parent or Legal Guardian*(Please use your mouse or finger on a touchscreen to sign in the box.)Typed Name of Parent or Legal Guardian*Relationship to Patient*Date* Untitled First Choice Second Choice Third Choice This iframe contains the logic required to handle Ajax powered Gravity Forms.