Form

Patient's Name

Date Of Birth

Sex

Age

Date Of Birth

If Child:Parent's Name

How do you wish to be addressed

Residence - Street

Address

City

Zip Code

Business Address

Telephone: Res.

Bus

Fax

Cell Phone

Patient/Parent Employed By

Present Position

How Long Held

Spouse/Parent Name

Spouse Employed By

Present Position

How Long Held

Who is Responsible for this account

Drivers License No.

Method of Payment

Purpose of Call

Other Family Members in this Practice

Whom may we thank for this referral

Patient/Parent Social Security No

Spouse/Parent Social Security No

Someone to notify in case of emergency not living with you

DENTAL INSURANCE 1ST COVERAGE

Employee Name

Date Of Birth

Relationship to patient

Employer Name

Yrs.

Name of Insurance Co.

Address

City

Zip Code

Telephone

Program or policy #

Social Security No

Union Local or Group

DENTAL INSURANCE 2ND COVERAGE

Employee Name

Date Of Birth

Relationship to patient

Employer Name

YRS.

Name of Insurance Co.

Address

City

Zip Code

Telephone

Program or policy #

Social Security No.

Union Local or Group

CONSENT:

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care oper ations that are related to treatment or payment. I consent to the disclosure of my records (or my child's records) to the following per sons who are involved in my care (or my child's care) or payment for that care.

My consent to disclosure of records shall be effective until I revoke it in writing. To authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for pay ment services not paid by my dental care payor. I attest to the accuracy of the information on this page

PATIENT'S OR GUARDIAN'S SIGNATURE

Date

CHILD DENTAL MEDICAL HISTORY

Patient's Name

Date Of Birth

Parent's Guardian's Name

DENTAL HISTORY - SELECT THE APPROPRIATE ANSWER

1. Is this your child's first visit to a dentist?

2. If not, how long since the last visit to the dentist?

3. Were any x-rays or radiographs taken when your child previously visited the dentist?

4. Does your child eat between meals?

5. Does your child eat sweets, such as candy, soda pop, chewing gum?

6. When does your child brush his/her teeth?

8. Have any cavities been noted in the past?

7. How does your child receive Fluoride?

level _ ppm

9. Does your child suck his/her thumb or fingers?

10. Were any teeth (baby or permanent) removed by extraction?

11. Was it suggested that the space be maintained

12. Was an appliance placed

13. Have there been any injuries to teeth, such as falls, blows, chips, etc?.

If so describe

14. Has your child had any problem with dental treatment in the past?

15. Has anyone in the family, including parents, had orthodontics?

16. Has your child ever received a local anesthetic?

17. Has your child ever had occlusal sealants?

18. Does your child think there is anything wrong with his/her teeth?

MEDICAL HISTORY

1. Does your child have a health problem?

2. Is your child under care of physician?

3. Name of physician

4. Is your child receiving any medication?

If YES, What?

5. Is your child allergic to penicillin, antibiotics or other drugs?

6. Is your child allergic to or sensitive to any metals or latex?

7. Does your child have other allergies?

8. Has your child had any serious illness?

When And What

9. Has your child ever had surgery?

10. Does your child have a heart murmur?

11. Is surgery contemplated?

12. Does your child experience severe or prolongated bleeding?

13. Does your child have AIDS or has he/she tested HIV positive?

14. Has your child tested positive for hepatitis?

15. Is your child subject to nervous disorders?

Select the appropriate answer

16. Does your child have frequent headaches?

Has your child had history of: (Select appropriate responses)

COMMENTS

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

PATIENT'S / GUARDIAN'S SIGNATURE

Date

DENTIST'S SIGNATURE

Date