Houston Dentistry For Children New Patient Form

• Tell Us About Your Child

• Child's Full Name *
• Child's Birthdate *
• Gender *
  Choose OneMaleFemale
• Name of school and grade that your child attends
• Hobbies, pets, sports, or special interests *

  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
• Parent or Legal Guardian's Full Name *
• Relationship to child *
• Birthdate *
• Home Address *
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazil----AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country
• Home Phone *
• Cell Phone
• Work Phone
  
• Email *
• Social Security Number *

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

• Driver's License Number *

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

• Employer & Occupation

• Spouse or Other Legal Parent or Guardian

• Spouse or Other Legal Parent or Guardian's Full Name
  
• Relationship to child
• Birthdate
  
• Home Phone
• Cell Phone
• Email

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

• Social Security Number

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

• Driver's License Number

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

• Employer & Occupation

• Emergency Contact Information

• Emergency Contact Name *
• Relationship to child
• Emergency Contact Number *

• 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.
• Full Name of person accompanying the child to his/her appointment *
• Relationship to child *

• 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

• Primary Insurance Company's Name *
• Insurance Company's Phone
  
• Group # (Plan, Local or Policy #)
• Policy Owner's Name *
• Policy Owner's Date of Birth *
• Policy Owner's Social Security Number *

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

• Policy Owner's Address
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazil----AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country

• Dual Insurance Coverage?

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

  yes no
• Secondary Insurance Company's Name
• Secondary Insurance Company's Phone
  
• Group # (Plan, Local or Policy #)
• Policy Owner's Full Name
• 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. *

  I acknowledge that I have read and agree to the above Terms and Conditions

• Child's Health History

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

  Require Antibiotics Prior to Treatment ADD/ADHD Allergies to Any Drugs Allergies to Latex Products Any Hospital Stays Any Operations Asthma Autism Cancer Congenital Birth Defects Convulsions/Epilespsy Diabetes Disabilities/Special Needs Hearing Impairment Heart Disease/Murmur Hemophilia/Blood Disorders Hepatitis HIV + / AIDS Kidney/Liver Conditions Pregnancy Rheumatic/Scarlet Fever Snoring Tuberculosis None of the above

  Please check any fields that relate to your child

• Please discuss any yes responses to the above conditions: *
• Please discuss any serious medical conditions, hospitalizations or operations your child has had (if none, write "none"): *
• List all drugs the child is currently taking (and dosage if known), or write "none" : *
• Has your child had their tonsils and/or adenoids removed *
• List all allergies to drugs or unfavorable reactions (or write "none"): *
• Is your child currently under the care of a physician or pediatrician? *

  Yes No
• Child's Physician/Pediatrician *
• Phone Number
• Explain reason for visit to physician (or write "routine"): *
• Are there any other details of your child's health that we should be aware of? *
• Please describe your child's current physical health *

  Good Fair Poor

• Dental History

• Siblings that we treat
• Is this your child's first visit to the dentist? *

  Yes No
• If no, how long since the last visit to the dentist?
• Previous Dentist's Name
• Were any x-rays taken at previous dental visits?
• How did you learn about our office? *

  If an individual, medical, or dental professional referred you, we'd like to thank them.

• List any injuries to the teeth, face or mouth or write "none", if no prior injuries. *
• Why did you bring the child to the dentist today? *
• If your child has ever had a serious or difficult problem associated with previous dental work, please explain, or write "none" if nothing exists. *
• Check any of the habits your child may have.

  Lip Sucking / Biting Nursing / Bottle Habits Nail Biting Thumb / Finger Sucking
• Check any of the following that apply to your child

  My child is taking fluoride supplements My child has bad breath Brushes his/her teeth 2x daily Flosses his/her teeth daily My child has had or currently has pain or tenderness in his/her jaw or TMJ

• ---

  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 *
  

• Do Not Fill This Out