Patient Registration Child Form

Patient Registration (Child)

Name:

First

Last

Email:

Sex

Male Female

Address:

Street Address

City:

State:

ZIP Code:

Birthday:

Social Security:

0 of 11 max characters

Best phone number to reach me at:

General Dentist:

Last Visited:

Who may we thank for referring you to our office?:

Parent's Name:

First

Last

Address (if different from Child):

Street Address

City:

State:

ZIP Code:

Social Security: 0 of 11 max characters

Best phone number to reach me at:

Policy Owner's Name:

First

Last

Social Security # or Subscriber ID:

Policy Owner's Employer:

Insurance Company:

Group No. (plan, local, or policy):

Insurance Phone No:

Do you have dual coverage?

Yes No

Medical History

Medical Physician:

Phone:

Last Visit:

Is the child under the care of a physician?

Yes No

If Yes, please explain:

Has puberty begun?

Yes No

Has menstruation (period) begun?

Yes No

Has the patient ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Does the patient have any missing or extra permanent teeth?

Yes No

Has the patient ever had an injury to : (select all that apply)

Teeth Mouth Chin

Does/Has the patient ever had any of the following habits?

Lip Sucking/Biting

Nail Biting

Mouth Breather

Tongue Thrusting

Clenching/Grinding Teeth

Prolonged Bottle/Pacifier

Thumb/Finger Sucking

Does the patient have speech problems?

Yes No

If Yes, please explain:

Is the child allergic to any of the following?

Aspirin

Erythromycin

Codeine

Penicillin

Tetracycline

Any Metals/Plastics

Other Allergies/Sensitivities:

List all drugs patient is currently taking:

List any serious medical condition(s) treated:

Signature

I understand that the information that I have provided is correct to the best of my knowledge, and that it will be held in the strictest of confidence

Name of person filling out this form:

First

Last

Date: