Houston Dentistry For Children 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.

(*) indicates a required field
  • Tell Us About Your Child

  • This question will help us communicate with and get to know your child better.

  • Parent or Legal Guardian's Information

    The following information applies to the main legal caregiver for the above named child

  • Please type in numbers only with no spaces or "-" dashes.

  • Please type in numbers only with no spaces or "-" dashes.

  • Spouse or Other Legal Parent or Guardian



  • Please type in numbers only with no spaces or "-" dashes.

  • Please type in numbers only with no spaces or "-" dashes.

  • Please type in numbers only with no spaces or "-" dashes.

  • Emergency Contact Information

  • Who Will be Accompanying the Child to His/Her Appointment?

    Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
  • Responsible Party / Billing Information

    Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
  • Dental Insurance Information


  • Please type in numbers only with no spaces or "-" dashes.

  • Dual Insurance Coverage?

    Please complete the following information if you have secondary dental coverage for your child.
  • Do you have dual (secondary) insurance coverage?

  • I assume financial responsibility for all dental treatment provided for my child, and understand that payment is expected on the date services are provided. I request and authorize my insurance company to pay the insurance benefits otherwise payable to me directly to the dentist. I understand that my insurance carrier may pay less than the actual bill for services and I, therefore, am ultimately responsible for payment of services rendered on my behalf or my dependents. I have thoroughly read and understand my obligations. *
  • Child's Health History

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

    Please check any fields that relate to your child

  • Is your child currently under the care of a physician or pediatrician? *
  • Please describe your child's current physical health *
  • Dental History

  • Is this your child's first visit to the dentist? *
  • If an individual, medical, or dental professional referred you, we'd like to thank them.

  • Check any of the habits your child may have.
  • Check any of the following that apply to your child

  • 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.)

    Today's Date *