Child Patient Information

Child Registration Form - Dental
* required field

Patient Information

Gender






Primary Phone Number





Parent/Guardian Information

Parents Marital Status
Relation







Phone Number
Secondary Phone Number

Relation







Phone
Secondary Phone Number


Emergency Contact









Insurance Information


























Dental History

How did you hear about our Practice?
Has your child tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?



Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?





Check if your child has or have ever had any of the following:

Authorization

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my childs health. It is my responsibility to inform the dental office of any changes in my childs medical status.I hereby authorize the release of any information pertaining to my childs medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my childs behalf for covered services and payment of any benefits to the office. I understand that I am financially responsible for any amount whether or not covered by insurance. I agree to pay all costs of collections including legal fees. I authorize the use of my signature on all insurance submissions.




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