Palatine Pediatric Dentistry

• Today's Date * MM/DD/YYYY

• Tell Us About Your Child

• Child's Name *
• Nickname
• Child's Birthdate * MM/DD/YYYY
• Gender *
  Choose OneMaleFemale
• Child'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
• Name of school and grade that your child attends (if any)
• Hobbies or special interests

  Although this question is optional it 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 (where the child lives)
• Parent or Legal Guardian's Name *
  
• Relationship to child *
• Birthdate * MM/DD/YYYY
• Home Phone * ### - ### - ####
• Additional Contact Phone
  ### - ### - ####
• Email *
• Social Security Number
  Must be between 9 and 9 digits.    Currently Used: 0 digits.

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

• Driver's License Number *
• Employer
• How did you learn about our office?

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

• Spouse or Other Legal Parent or Guardian

• Spouse or Other Legal Parent or Guardian's Name
• Relationship to child
• Birthdate MM/DD/YYYY
• Home Phone ### - ### - ####
• Additional Contact Phone ### - ### - ####
• Social Security Number
  Must be between 9 and 9 digits.    Currently Used: 0 digits.

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

• Driver's License Number
• Employer

• 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.
• Person accompanying the child to his/her appointment  *
• Relationship to child  *
• Do you have legal custody of this child? *

  Yes No

• 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.
• Responsible Party's Name  *
• Relationship to child
• Billing Address (If same as child's address above, you may leave this section blank)
  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 * ### - ### - ####
• Additional Contact Phone ### - ### - ####
• Email

• Dental Insurance Information

• Primary Dental Insurance Company's Name
• Primary Dental Insurance Company's Address
• Insurance Company's Phone ### - ### - ####
• Group # (Plan, Local or Policy #)
• Insured's Name
• Relationship to child
• Employer
• Social Security Number
  Must be between 9 and 9 digits.    Currently Used: 0 digits.

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

• Birthdate MM/DD/YYYY

• 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 Dental Insurance Company's Name
• Secondary Insurance Company's Address
• Secondary Dental Insurance Company's Phone
  ### - ### - ####
• Group # (Plan, Local or Policy #)
• Insured's Name
• Relationship to child
• Employer
• Social Security Number
  Must be between 9 and 9 digits.    Currently Used: 0 digits.

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

• Birthdate MM/DD/YYYY

• Child's Health History

• Is your child experiencing or have they ever experienced any of the following conditions? *

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

  Please check any fields that relate to your child

• Please list any serious medical conditions your child is experiencing or has experienced (if none, write "none"): *
• List all drugs (prescription or over the counter) your child is currently taking (and dosage if known), or write "none" : *
• List all allergies (or write "none"): *
• Child's Physician *
• Physician's Phone Number ### - ### - ####
• Is your child currently being monitored by a physician for any reason other then routine care? *

  Yes No
• Explain
• 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

• 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?
• List any injuries to the teeth, face or mouth. Write "none", if no prior injuries.
  *
• Why are you bringing your 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
• Is your child currently using or have a history of tobacco use?

  Yes No
• Check any of the following that apply to your child

  Our drinking water is fluoridated My child is taking fluoride supplements Brushes his/her teeth daily Uses a toothpaste containing fluoride Uses a mouth rinse containing fluoride Flosses his/her teeth daily I help my child with their brushing and flossing Either parent has had a problem with tooth decay Either parent has had orthodontic treatment I hear my child grinding their teeth during the night