Marcy L. Keown Pediatric Dentistry 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
Child's Home Address *
2. Mother's Information
Relationship to Child *
Mother's Home Address *
3. Father's Information
Relationship to Child
Father's Home Address
5. Who Is Accompanying Your Child Today?
6. Person Responsible for Account
7. Primary Dental Insurance
8. Secondary Dental Insurance
9. Dental History
Why did you bring your child to the dentist today?
Does the child have any of the following habits? *
10. Health History
Has the child ever had any of the following conditions? *
Please discuss any serious medical 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) *
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
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.)