Just for Kids New Patient Dental/Health Form

We sincerely welcome you and your child into our practice We will make you rdental visits as pleasant as we can. In order for us to better understand your child, please complete this form as thoroughly as possible. Thank you.

(*) indicates a required field.

Acquaintance Record

Today's Date

Child's Full Name

Nickname

Gender

Child's Birthdate

Child's Age

Weight

Whom may we thank for referring you to our office?

Who is the child's legal guardian?

Are parents married, divorced, seperated, remarried, or deceased?

Any special circumstances that would help us treat your child?

Father / Legal Guardian

Date of Birth

Social Security Number

Driver's License Number

Street Address

City

State

Zip Code

Telephone (home)

Telephone (work)

Employer

Cell

Other Number

Email

Mother / Legal Guardian

Date of Birth

Social Security Number

Driver's License Number

Street Address

City

State

Zip Code

Telephone (home)

Telephone (work)

Employer

Cell

Other Number

Email

Name of Siblings?

Which siblings have we treated?

What is the best method of contact:

With whom should we confirm:

Text

Email

Phone

Dental Insurance Information

Insured Name

Employer

Group Number

Insurance Company

Insurance Company Telephone

Subscriber ID Number

Dental History

Is this your child's first visit to our office? *

What is your main concern for this visit?

Has your child been seen in any other dental office?

If so, where

Date of last dental exam

Last X-rays

Has your child experience any unfavorable reaction from any previous medical or dental care? (state which)

Does your child have any mouth habits such as thumb sucking?

If so, please explain

Does your child brush every day?

Do you assist with brushing or flossing?

Is your child still breast or bottle feeding?

Medical History

Child's Physician

Date of Last Visit

Has your child ever been diagnosed with heart diseas or heart murmur?

If yes, please explain

Does your child have any shunts, pins, screws, rods, or artificial joints?

If yes, please explain

Has your child ever had surgery?

If yes, please explain

Is your child in good general health?

Has your child had or does he/she have now:

If allergic reactions to medications, what are they?

If your child is taking medications, what are they?

If your child is special needs, please explain:

Person to contact in case of emergency (not living at home)

Name

Relationship

Street Address

City

State

Zip Code

Telephone (home)

Telephone (work)

In order to provide your child with optimum care, we draw upon the knowledge of the entire staff of doctors in consultation, diagnosis and treatment of all patients. The undersigned hereby authorizes this dental office to perform the examination and after explanation, the necessary dental services deemed appropriate for the care of the above named child and furthermore, will be responsible for charges incurred from said dental patient.

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

Date *