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Menu
Home
About Us
Meet the Team
Office Tour
Patients
First Visit
Patient Handouts
Services
Forms
New Patient Forms
Existing Patient Forms
Physician Referral Form
Dentist Referral Form
Reviews
Contact Us
Make Payment
Pay with Care Credit
Home
About Us
Meet the Team
Office Tour
Patients
First Visit
Patient Handouts
Services
Forms
New Patient Forms
Existing Patient Forms
Physician Referral Form
Dentist Referral Form
Reviews
Contact Us
Menu
Home
About Us
Meet the Team
Office Tour
Patients
First Visit
Patient Handouts
Services
Forms
New Patient Forms
Existing Patient Forms
Physician Referral Form
Dentist Referral Form
Reviews
Contact Us
Please complete this form for new patients ages 0-17.
Today's Date
Child's Name *
First Name
Last Name
Nickname
Birthday
Age
Gender
Male
Female
Weight
How did you hear about our office?
If online please let us know which site (Google, Facebook etc.)
Parent's Name
First Name
Last Name
Relationship to child
Parent's Birthday
Phone Number
Address
Address 1
City
State/Province
Zip/Postal Code
Country
Email Address
Occupation/Employer
Additional Parent or Guardian
Dental Insurance Company
Name of Subscriber
First Name
Last Name
Subscriber's Birthday
Subscriber or Member ID Number
Name of Pediatrician
Name of Any Medical Specialists
Please list any medications (prescriptions, vitamins or supplements)
Please list any allergies
Please list any hospitalizations, surgeries or other significant injury/illness
Medical History
For the following questions you only need to click if the answer is yes. Please provide details at the end of the section for any positive responses.
Was your child born prematurely (before 36 weeks gestation) ?
Yes
If yes, what week and please describe any complications after birth
Any Problems with growth & development, birth defects, syndromes or inherited conditions?
Yes
Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat or high blood pressure
Yes
Asthma or breathing problems
Yes
Bladder and/or kidney problems
Yes
Jaundice, hepatitis or liver problems
Yes
Gastroesophageal/acid reflux or stomach problems
Yes
Developmental disorder, learning problems/delays, autism, cerebral palsy, ADD/ADHD
Yes
Epilepsy, convulsions/seizures
Yes
Diabetes, thyroid or other endocrine problems
Yes
Hemophilia, bleeding disorder or taking anticoagulation medications
Yes
Cancer or other malignancies
Yes
History of problems with sedation and/or anesthesia
Yes
Infectious diseases (hepatitis, HIV/AIDS, MRSA, Tuberculosis, endocarditis, frequent/recurrent infections, or infections requiring hospitalization/IV antibiotics
Yes
If yes to any of the above or other medical problems we should know about, please explain below
Dental History
Any particular concerns for your child's teeth?
Any history of cavities, traumatic injuries or other dental problems?
Any jaw joint problems (pain, clicking or popping)?
Yes
Does your child have any habits?
Thumb or finger sucking
Pacifier
Mouth breathing
Grinding/clenching
Nail Biting
Other
Does your child sleep with a bottle or sippy cup? (Ages 5 and under only)
Yes
What does your child drink most often?
What kind of toothpaste do you use? *
With fluoride
Without fluoride
Not sure
Has your child ever undergone orthodontic treatment?
Has your child ever had a difficult dental appointment? *
Yes
No
If yes please explain
Reason for changing dentists (if applicable)
Is there anything else we should know before treating your child?
Send
