Sprouts Pediatric Dentistry New Patient Form

Please answer the following questions. This will assist us in getting to know your child and provide the best possible care. Thank you!

(*) indicates a required field.

1. Tell Us About Your Child/Children

Today's Date *

Child's Name *

Date of Birth *

Nickname

Gender

Address *

Apt #

City *

State *

Zip Code *

Siblings that we also care for:

Hobbies or special interests:

How did you learn about our office:

Parent or Legal Guardian's Information

The information in this section applies to the main legal caregiver of the child / children.

Name *

Relationship to Child *

Birthdate *

Street Address *

Apt #

City *

State *

Zip Code *

Employer

Work Number

Home Number *

Cell Number

Social Security Number

Email Address *

Other Parent or Legal Guardian

(If different from #2 above.)

Name

Relationship to Child

Birthdate

Street Address

Apt #

City

State

Zip Code

Employer

Work Number

Home Number

Cell Number

Social Security Number

Email Address

Responsible Party / Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Insurance ID #

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

Dual Insurance

Do you have dual (secondary) insurance?

Insurance Company Name

Medical History

Child's Primary Physician and Office:

Are you child's immunizations up to date? *

Has your child ever been hospitalized or had a surgery? *

If yes, please explain:

Is your child taking any PRESCRIPTION medications? *

If yes, please list:

Is your child taking any over the counter medications, vitamins or supplements? *

If yes, please list:

Does your child have any drugs allergies? *

If yes, please list:

Does your child have any other non drug allergies (seasonal, food etc.)? *

If yes, please list:

Has your child ever had any of the following conditions? *

Please explain any of the above checked items or medical conditions/treatments for your child. (If none, please write NONE)

Were there any complications or problems during pregnancy or delivery?

If yes, please explain:

Describe your child's current physical health. *

Dental History

Is this your child's first visit to the dentist? *

Does your child have any dental problems are cavities you are aware of? *

If yes, please explain:

Has your child had any injuries to the teeth, face or mouth? *

If yes, please explain:

Does your child use a mouth guard for sports? *

If yes, what sports?

Has your child ever had a negative experience or problem associated with previous dental visits? *

If yes, please explain:

Please check any of the habits your child has/had.

Was/Is your child breast or bottle fed? *

If yes, to what age were they breast or bottle fed?

Does your child sleep or nap with a bottle or feed throughout the night? *

Does your child drink milk, juice, pop or soda on a regular basis or throughout the day? *

Does your child drink fluoridated tap water? *

Has your child ever taken a PRESCRIPTION fluoride supplement? *

If yes, what was the supplement?

Does your child use a flouride toothpaste? *

How often are your child's teeth brushed? *

How often are your child's teeth flossed? *

Who brushes and flosses your child's teeth? *

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status.

Relationship to Patient *

Date *