Stagecoach Children's Dental Center 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 *
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Child's Full Name *

Nickname

Gender *

Siblings We Treat

Child's Birthdate *
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Child's Age

School

Child's Home Number

Social Security Number *


Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


2. Mother's Information

Name *

Relationship to Child *

Birthdate *
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Mother's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


Employer

Work Number

Home Number *

Cell Number

Social Security Number *

Driver's License Number *

Email Address *


3. Father's Information

Name

Relationship to Child

Birthdate
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Father's Home Address

Street Address

Apt #

City

State

Zip Code


Employer

Work Number

Home Number

Cell Number

Social Security Number

Driver's License Number

Email Address


4. Who May We Thank For Referring You?

Name


5. Who Is Accompanying Your Child Today?

Name *

Relationship *

Do you have legal custody of this child? *


6. Person Responsible for Account

Name *

Relationship

Billing Address

Apt #

City

State

Zip Code

Work Number

Home Number *

Cell Number

Email Address


7. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
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Policy Owner's SSN

Policy Owner's Employer


8. Secondary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
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Policy Owner's SSN

Policy Owner's Employer


9. 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 x-rays taken at previous dental visits?


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?


Does the child have any of the following habits? *

Lip Sucking / Biting:

Nursing / Bottle Habits:

Nail Biting:

Thumb / Finger Sucking:


Has the child ever had a serious or difficult problem associated with previous dental work? *

If yes, please explain:


Is this child's water fluoridated?

Is the child taking fluoride supplements?

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?


10. 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

Rheumatic/Scarlet Fever

Allergies to Latex Product

Diabetes

Hemophilia/Blood Disorders

Reflux/GI Problems


Please discuss any serious medication conditions the child has had: (or write NONE) *

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

Is this child currently under the care of a physician? *

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.


11. 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 *
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