Step 1 of 10 10% Tell Us About Your ChildToday's Date* MM slash DD slash YYYY Child's Full Name* Nickname Gender*MaleFemaleChild's Birthdate* MM slash DD slash YYYY Child's Age*School Siblings We Treat How 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* MM slash DD slash YYYY Marital Status Single Married Divorced Widowed Parent or Legal Guardian's Home AddressStreet Address* Apt # City* State* Zip Code* Employer Work NumberHome Number*Cell NumberSocial Security Number* Driver's License Number Email Address* Spouse or Other Legal Guardian's Information(If different from #2 above)Name* Relationship to Child* Birthdate* MM slash DD slash YYYY Marital Status Single Married Divorced Widowed Spouse or Other Legal Guardian's Home AddressStreet Address* Apt # City* State* Zip Code* Employer Work NumberHome Number*Cell NumberSocial Security Number* Driver's License Number Email 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?* Yes No Primary Dental InsuranceInsurance Company Name Insurance Co. Address Unit # City State Zip Code Insurance Co. PhoneGroup # (Plan, Local or Policy #) Insurance ID # Policy Owner's Name Relationship to Patient Policy Owner's Birthdate MM slash DD slash YYYY Policy Owner's SSNPolicy Owner's Employer Dual (Secondary) InsuranceDo you have dual (secondary) insurance? Yes No Insurance Company Name Dental HistoryIs this your child's first visit to a dentist?* Yes No If no, how long since the last visit to a dentist? Previous Dentist's Name Date of Last X-Rays at Previous Dental Visits Have there been any injuries to the teeth, face or mouth?* Yes No If 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? Yes No If yes, please explain:Is your child's water fluoridated? Yes No Does your child brush his/her teeth daily? Yes No Is your child taking fluoride supplements? Yes No Does your child floss his/her teeth daily? Yes No Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)? Yes No Social HistoryChild's First Language* Child's Second Language Health 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 Number Is your child currently under the care of a physician?* Yes No Describe your child's current physical health.* Good Fair Poor 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* MM slash DD slash YYYY
