Patient Registration Form

Page 1 of 4

Tell us about your child

Patient Name

Date of Birth

Age

Social Security Number

Nickname

Gender

Male

Female

Hobbies

School

Physical Address

City

State

Zip

Mailing Address

City

State

Zip

Phone Number

Email Address

Are other family members seen by us?

What is the reason for your visit?

Who is accompanying the child today?

Name

What is your relationship to the child?

Do you have legal custody of this child?

Yes

In the case of an emergency please contact the following person.

Name

Phone

What is the name and phone number of the nearest relative who is not living with you?

Parent Information

Married

Single

Guardian

Step-parent

Foster parent

Name

Social Security Number

Date of Birth

Employer

Work Phone

Home Phone

Alternative Phone Number

Drivers License

Expiration

Parent Information

Married

Single

Guardian

Step-parent

Foster Parent

Name

Social Security Number

Date of Birth

Employer

Work Phone

Home Phone

Alternative Phone Number

Drivers License

Expiration

Page 2 of 4

Insurance Information

Insured's Name

Date of Birth

Member ID Number

Social Security Number

Relationship to Patient

Employer

Employer's Phone Number

Employer's Address

Insurance Company Name

Insurance Company Address

State

Zip

Insurance Company Phone

Group Plan or Policy

Whom may we thank for referring you?

Name

Patient

Doctor

Other

Address

Phone

Page 3 of 4

Dental and Medical History

What is the name of child's general dentist?

Date of last dental visit?

For what service?

Has your child had any injuries to the mouth, teeth, or head?

Has your child had an unhappy dental experience in the past?

Child's pediatrician

Phone Number

Date of last visit?

Is your child currently under the care of a physician?

Yes

Please describe your child's current physical health.

Good

Fair

Poor

Please list all drugs and food that the child is allergic to and the type of reaction.

Line 2

Line 3

Line 4

Please list all the medications and supplements that the child is currently taking.

Line 2

Line 3

Line 4

Line 5

Does your child have any of the following habits?

Thumb or finger sucking

Yes

Lip biting or sucking

Yes

Nail biting

Yes

Nursing, bottle, or sippy cup?

Yes

Mouth breathing

Yes

Nighttime grinding of teeth

Yes

Does your child have a heart condition such as a heart murmur?

Yes

If yes, please explain

Who is the child's cardiologist?

Phone number

Page 4 of 4

Health History

Does the child have or has ever had the following medical conditions?

Cancer or tumors

Yes

Diabetes

Yes

Rheumatic fever

Yes

HIV or AIDS

Yes

Hemophilia

Yes

Asthma

Yes

Hepatitis

Yes

Tuberculosis

Yes

Chronic upper respiratory problems

Yes

Convulsions or epilepsy

Yes

Abnormal bleeding

Yes

Hearing impairment

Yes

Vision problems

Yes

Any operations

Yes

Please explain any medical operations

Any hospital stays

Yes

Please explain any hospital stays

Kidney or liver problems

Yes

Handicaps or disabilities

Yes

Allergies

Yes

Peanut allergy

Yes

Pregnant

Yes

Smoker

Yes

ADD and/or ADHD

Yes

Developmentally delayed

Yes

Autism

Yes

Down syndrome

Yes

Speech problems

Yes

I UNDERSTAND THAT THE INFORMATION THAT I HAVE GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE, THAT IT WILL BE HELD IN THE STRICTEST OF CONFIDENCE, AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY CHILD'S MEDICAL STATUS. I ALSO AUTHORIZE THE DOCTORS AND THE DENTAL STAFF TO PERFORM ANY NECESSARY DENTAL SERVICES MY CHILD MAY NEED. THE RESPONSIBLE PARTY IS THE PARENT WHO BRINGS THE CHILD TO THE DENTAL OFFICE, INDEPENDENT OF WHAT A DIVORCE DECREE MAY STATE. REIMBURSEMENT MUST BE MADE BETWEEN THE DIVORCED PARTIES. WE WILL NOT INTERVENE.

Full Name

disregard this