New Patient Dental/Health 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.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Child's Birthdate *

Child's Age

School

Siblings We Treat

Does your child have any special interests that we should be aware of? (Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.)

Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Child's Home Number

Do we have a current Financial/Insurance Form on file for this child that has up-to-date billing and insurance information? *
(If not, please complete one prior to your child's visit on our website.)
Yes No

2. Dental History

Is this your child's first visit to a dentist? *
Yes No

If not, how long since the last visit to a dentist?

Previous Dentist's Name

Date of Last X-Rays at Previous Dental Visits

Have there been any injuries to the teeth, face or mouth? *
Yes No

If yes, please explain:

Why did you bring your child to the dentist today?

Does your child have any of the following habits?

Lip Sucking / Biting

Nursing / Bottle Habits

Tobacco Use

Nail Biting

Thumb / Finger Sucking

Does your child have any current dental issues?

Cavities

Bleeding Gums

Bad Breath

Mouth Trauma/Broken Tooth

Toothache

Discolored Teeth

Teeth Grinding

Sensitivity to Hot/Cold

Has your child ever had a serious or difficult problem associated with previous dental work? *
Yes No

If yes, please explain:

Is your child's water fluoridated?
Yes No

Is your child taking fluoride supplements?
Yes No

Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?
Yes No

Does your child brush his/her teeth daily?
Yes No

Does your child floss his/her teeth daily?
Yes No

3. Social History

Child's First Language *

Child's Second Language

4. Health History

Has your child ever had any of the following conditions? REQUIRED

If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please do so below.

List all drugs your child is currently taking (or write NONE). *

List all allergies your child currently has (or write NONE). *

Child's Physician *

Phone Number

Is your child currently under the care of a physician? *
Yes No

Describe your child's current physical health. *
Good Fair Poor

5. Acknowledgement of Receipt of Notice of Privacy Practices

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by your office of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the rights to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment. Payment in health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient Name
Relationship to Patient
Signature of Parent or Legal Guardian (please use your mouse or finger on a touchscreen to sign in the box)

Reset Signature

6. Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)