Dr. Janice Work 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.)

2. Dental History

Is this your child's first visit to a dentist? *

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? *

If yes, please explain:


Why did you bring your child to the dentist today?


Does your child have any of the following habits?

Does your child have any current dental issues?


Has your child ever had a serious or difficult problem associated with previous dental work? *

If yes, please explain:


Is your child's water fluoridated?

Is your child taking fluoride supplements?

Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?

Does your child brush his/her teeth daily?

Does your child floss his/her teeth daily?

3. Social History

Child's First Language *

Child's Second Language

4. Health History

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


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? *

Describe your child's current physical health. *

5. 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.)

Relationship to Patient *

Date *