About Your Child

Patient Information

Child's Legal Name

Nickname (what they like to be called)

Date of Birth

Age

Sex

School / Grade

Primary Pediatrician

Date of Last Physical Exam

Parent or Guardian

Primary Contact

Full Name

Relationship to Child

Street Address

City

State / ZIP

Mobile Phone

Work Phone

Preferred Contact

Email Address

Employer

Second Parent / Guardian Name

Phone

Dental History

Tell Us About Their Teeth

Is this your child's first dental visit? If not, when was their last visit?

☐ Yes☐ No

Does your child currently suck their thumb, fingers, or use a pacifier?

☐ Yes☐ No

Does your child drink fluoridated tap water at home?

☐ Yes☐ No

Does your child use fluoride toothpaste? How many times per day do they brush?

☐ Yes☐ No

Has your child ever had a dental injury, chipped tooth, or oral trauma?

☐ Yes☐ No

Does your child grind their teeth, snore, or breathe through their mouth at night?

☐ Yes☐ No

Any current dental concerns you'd like us to know about

Medical Conditions

Health Overview

Please check any conditions your child has or has had:

Asthma

Allergies (food or drug)

ADHD / ADD

Autism Spectrum

Diabetes

Heart Condition

Epilepsy / Seizures

Hearing Impairment

Vision Impairment

Kidney Issues

Bleeding Disorder

Anxiety

Developmental Delay

Frequent Ear Infections

Prior Hospitalization

Current Medications (include dosage)

Known Allergies

Has your child had anesthesia before? If yes, reaction?

Immunizations up to date?

Dental Insurance

Billing Information

Insurance Company

Plan / Group Number

Subscriber / Policy Holder Name

Subscriber DOB

Member ID

Subscriber Employer

Relationship to Patient

Consent & Acknowledgement

Please Read Carefully

New Patient Intake Form

Authorization for Treatment