Houston's Pediatric Dentist
New Patient Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party. We are fully compliant with all HIPAA Regulations.
Note: The parent or guardian who accompanies the child is responsible for payment at the time of service.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Siblings We Treat

Child's Birthdate *

Child's Age *

School and Grade (or write NONE) *

Is Your Child adopted? *


Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


2. Mother's Information

Name *

Relationship to Child *

Birthdate *

Marital Status *


Mother's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


Employer (or write NONE) *

Work Number

Home Number

Cell Number *

Social Security Number *

Email Address *


3. Father's Information

Name *

Marital Status *

Relationship to Child

Birthdate


Father's Home Address

Street Address *

Apt #

City *

State *

Zip Code *


Employer (or write NONE) *

Work Number

Home Number

Cell Number *

Social Security Number *

Email Address *


4. How Did You Hear About Our Office? * (if internet please say where specifically)


5. Who Is Accompanying Your Child Today?

Name

Relationship

Do you have legal custody of this child?


6. Primary Dental Insurance (or write NONE or N/A)

Insurance Company Name *

Insurance Co. Address *

Unit # *

City *

State *

Zip Code *

Insurance Co. Phone

Subscriber ID or Policy #

Group # Plan, Local or Policy # *

Policy Owner's Name *

Relationship to Patient


7. Dental History

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

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

Previous Dentist's Name

Were Any Dental X-rays Taken in the Last 12 Months?


Have there been any injuries to the teeth, face or mouth? *

If yes, please explain:


Why did you bring your child to the dentist today?

If your child has ever had a serious or difficult problem associated with previous dental work, please explain.


Does the child have any of the following habits? *

Pacifier:

Nursing / Bottle Habits:

Nail Biting:

Thumb / Finger Sucking:


Is this child's water fluoridated?

Has the child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?

Does the child brush his/her teeth daily?

Floss his/her teeth daily?


8. Health History

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

Abnormal Bleeding

Allergies to Any Drugs

Any Hospital Stays

Any Operations

Asthma

Cancer

Handicaps/Disabilities

Hearing Impairment

Heart Disease/Murmur

Hepatitis

HIV + / AIDS

Kidney/Liver Conditions

Congenital Birth Defects

Convulsions/Epilepsy

Pregnancy

Tuberculosis

ADD/ADHD

Autism/Sensory Issues

Rheumatic/Scarlet Fever

Allergies to Latex Product

Diabetes

Hemophilia/Blood Disorders

Reflux/GI Problems


Please discuss any serious medical conditions the child has had to include any hospitalizations or operations: (or write NONE) *

Does your child need premedication with antibiotics before dental treatment?

 

Please list all the drugs the child is currently taking: (or write NONE) *

Please list all drugs the child is allergic to: (or write NONE) *

Child's Physician *

Phone Number

Are there any other details of your child’s health that we should be aware of? (or write NONE) *

Please describe the child's current physical health *


Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


9. Signature

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *