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Patient Registration and Medical History

Welcome to our pediatric dental practice. To save time during your first visit, please complete the following patient information form. Thank you, and we look forward to seeing you and your child soon!

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PATIENT INFORMATION
Patient's Name*
First Middle Last
Date of Birth*
Gender
- Male
- Female
Parent/Guardian's Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone*
Email
Who is responsible for this account?*
First Last
Other family members in this practice?
Who referred you to this practice?
Emergency Contact: Name*
First Last
Emergency Contact: Phone*

DENTAL INSURANCE
Cash Pay?*
- Yes
- No
PRIMARY COVERAGE
Insurance Co. Name
Insurance Co. Address
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone
Policy #
Insured's Name
First Last
Date of Birth
Relationship to Patient
Social Security No.

DENTAL INSURANCE
- Not Applicable
SECONDARY COVERAGE
Insurance Co. Name
Insurance Co. Address
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone
Policy #
Insured's Name
First Last
Date of Birth
Relationship to Patient
Social Security No.

MEDICAL HISTORY
Does your child have any health problems?*
- Yes
- No
If yes, please describe.*
Is your child under the care of a pediatrician?*
- Yes
- No
If yes, who?*
Is your child being seen for any other medical reasons?*
- Yes
- No
If yes, who?*
Is your child taking any medications?*
- Yes
- No
If yes, what?*
Is your child allergic to any medicines?*
- Yes
- No
If yes, what?*
- Penicillin
- Other
If other, please describe.*
Is your child sensitive/allergic to any metals or latex?*
- Yes
- No
Is your child allergic to anything else?*
- Yes
- No
If yes, what?*
Does your child have a history of any serious illness?*
- Yes
- No
If yes, when and what?*

You are almost done! Just a few more questions that will help us better serve you and your child.
MEDICAL HISTORY
Has your child ever had surgery?*
- Yes
- No
Does your child have a heart murmur?*
- Yes
- No
Does your child experience excessive bleeding?*
- Yes
- No
Has your child tested positive for HIV/AIDS?*
- Yes
- No
Has your child tested positive for hepatitis?*
- Yes
- No
Is your child subject to nervous disorders?*
- Yes
- No
If yes, what?*
Has your child had any history of, or conditions related to, any of the following?*
- Anemia
- Asthma
- Cancer
- Cerebal Palsy
- Diabetes
- Fainting
- Hearing
- Heart
- Kidney
- Liver
- Rheumatic Fever
- Seizures/Epilepsy
- Thyroid
- Vision
- Other
- None
If other, please describe.*

DENTAL HISTORY
Is this the first time at the dentist?*
- Yes
- No
Any dental disease in the past or present?*
- Yes
- No
If yes, what?*
Has your child ever had dental x-rays?*
- Yes
- No
If yes, when?*
How often does your child brush?*
- Never
- Seldom
- 1x/day
- 2x/day
How often does your child floss?*
- Never
- Seldom
- 1x/day
- 2x/day
How often does your child visit the dentist?*
- Never/First Visit
- Seldom
- 1x/yr
- 2x/yr
Does your child have access to sugary snacks, processed foods, or sweetened drinks between meals?*
- Yes
- No
Is there a history of dental trauma or dental injuries?*
- Yes
- No

DENTAL HISTORY
How do you think your child will behave at the dentist?*
- No problem
- Slight anxiety
- Very anxious
What strategies have worked before to help calm your child?
Does your child's bite or the appearance of his/her smile concern you?*
- Yes
- No
Do you have any other dental concerns for your child?*
- Yes
- No
If yes, what?*
What is the biggest dental concern for your child?*
Do you have any advice for the dentist to help your child have a successful visit and good experience?

SIGNATURE
I certify that the information on this form is complete and accurate. I authorize the dental staff to perform the necessary dental services my child may need.
Patient's / Guardian's Signature*
Date*
MM slash DD slash YYYY

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