Patient Registration and Medical History

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*

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!