New Patient Health and Financial 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
Child's Home Address *
2. Parent or Legal Guardian's Information
The information in this section applies to the main legal caregiver of the child / children.
Parent or Legal Guardian's Home Address *
3. Spouse or Other Legal Guardian's Information
(If different from #2 above.)
Spouse or Other Legal Guardian's Home Address
5. Who Will Be Accompanying the Child/Children to Their Appointment?
Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.
6. Person Responsible for Account
7. Primary Dental Insurance
8. Dental History
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?
9. Social History
10. Health History
Has your child ever had any of the following conditions? *
Please check all that apply and if none, please check "None of the Above"
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 explain below.
List all drugs your child is currently taking (or write NONE). *
List all allergies your child currently has (or write NONE). *
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.)