Confidential Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Cell Phone:
* Email:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Please list the name and age of any siblings
How did you hear about us?



If you answered Family/Friend or Referral from a Professional, please list them here:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
Relationship to Patient:
Email:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # or Social Security Number:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # or Social Security Number:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Health History

List any medications currently being taken by the patient:
List any known allergies or sensitivities including drug allergies or food allergies:
Please select YES or No for the Following Questions - Do Not Leave Blank
* Prematurity
* Heart Murmur
* Congenital Heart Defect
* Other Heart Disease (e.g. arrhythmias)
* Asthma or Reactive Airway Disease
* Frequent Cough, Bronchitis, Pneumonia
* Other Lung Disease
* Kidney Disease
* Liver Disease
* Seizures, Epilepsy, or Other Neurologic Disorder
* Blood or Bleeding Disorders (e.g. Anemia, Hemophilia)
* Endocrine Disorders (e.g. Diabetes, Thyroid Disease)
* GI Disorders (e.g. GERD, Celiac, Crohn's)
* Skin Problems (e.g. Eczema, Rash/Hives)
* Growth Problems, Hormone Therapy
* Muscle, Joint, or Bone Disorders (e.g. Juvenile Arthritis)
* Infectious Disease History (e.g. HIV, Tuberculosis)
* Autism Spectrum Disorder
* ADHD
* Developmental Delay, Other Disabilities
* Mood Disorder (e.g. Depression, Anxiety, Psychiatric Treatment)
* History of Cancer or Radiation Therapy
* History of Hospitalization or Surgeries
* Tonsils and Adenoids Removed
Other Problem not listed:
If any of the above medical questions were answered 'Yes' , please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:

Dental History

Reason For Visit:
Please select Yes/No for the following, occurring in the past or present
* Is this your child's first dental visit?
* Speech problems/therapy?
* Grind or clench teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting, pacifier use)?
* Use non-fluoride toothpaste?
* Frequent sore throats?
* Mouth breathing?
* Snores during sleep?
* Requires premedication?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Has your child had a negative dental experience in the past?
If any of the above dental questions were answered 'Yes', please explain:
Anything else about your child that you think we should know in order to better treat their dental needs?

Oral Hygiene

Brushing Frequency per day
Flossing Frequency per day
Juice or Sweetened Beverage intake per day
Snacking sessions per day
Previous Dentist Name:
Date of Last Dental X-rays:
Last Dental Visit:

Orthodontic History

Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?
I received the Photo Policies, and