Patient Biographical Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Village/Subdivision:
Email:
Primary Phone:
Secondary Phone:
Name of school:
Grade:
Special interests, sports, or hobbies:
Patient's Dentist:
Phone #:
Please list any other family members we have treated:

Whom can we thank for this referral?
Dentist:
Friends:
Friends:
Friends:
Other:

Name of person accompanying child to appointment:
Relationship:

Siblings

Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:

Guardian 1

First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (please update if different)
City:
State:
Zip:
Relationship to Patient:
Marital Status:
Social Security #:
Primary Phone:
Secondary Phone:
Email:
Employer:

Guardian 2

First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (if different)
City:
State:
Zip:
Relationship to Patient:
Marital Status:
Social Security #:
Primary Phone:
Secondary Phone:
Email:
Employer:

Person Responsible for Financials

Who is responsible for account:
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Primary Phone:
Cell:
Work:
Email:
Social Security #:
Employer:

Primary Dental Insurance Information

Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:

Secondary Dental Insurance Information

Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:

Medical History

Please select YES if the patient has had any of the conditions listed below either now or in the past.
Heart Murmur/Congenital Defect
Diabetes
Rheumatic Fever
Cancer
HIV/AIDS
Hemophilia
Blood Transfusions
Asthma
Hepatitis
Tuberculosis
Heart Problems
Sinus Problems
Hypertension/High Blood Pressure
Convulsions/Epilepsy
Abdominal Bleeding
Hearing Impairment
Operations/Stays in a Hospital
Kidney/Liver Problems
Handicaps/Disabilities
Allergies to Drugs, Metals, or Foods
Antibiotics Prior to Dental Treatment
Other Medical Problems
Currently Taking Medication
* Currently Pregnant
If any of the above medical questions were answered 'Yes' , please explain:

Dental History

Please select YES if the patient has had any of the conditions listed below either now or in the past.
Injuries to Face/Teeth
Other Orthodontic Treatment
Pain/Noises in the Jaw Joint (TMJ)
Root Resorption
Periodontal Disease
Unfavorable Dental Experience
Missing Teeth
Extra Teeth
Finger Sucking
Tongue Thrusting
Speech Problems
Mouth Breathing
Gums Bleed
Grind Teeth
If any of the above dental questions were answered 'Yes', please explain:
What do you see as the main problem with your teeth?

Emergency Information

Who should we contact in the event of an emergency?
Phone:
Relationship to Patient:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.