Child Patient Information

Child Registration Form - Dental
* required field

Patient Information

Gender





Primary Phone Number




Parent/Guardian Information

Parents' Marital Status
Relation







Phone Number
Secondary Phone Number

Relation







Phone
Secondary Phone Number

Emergency Contact








Insurance Information

























Dental History

How did you hear about our Practice?
Has your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does your child you have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?



Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?





Check if your child has or have ever had any of the following:

Broken Appointment Policy

Broken Appointment Policy Our office has set many goals, and one of our main goals is to be more responsive to your scheduling needs. We value our patients' time and expect the same in return. One area of scheduling that causes us concern is a Broken Appointment. A broken appointment is defined as not showing up to a scheduled appointment, a 'late cancellation' (cancelling within 24 hours of your appointment), or being 10 minutes tardy. In order to schedule properly and minimize the amount of time between appointment dates, we ask that all our patients keep their appointment times. We call, text, and/or email a week prior to your appointment and the day of to remind you. We ask that you call or text us back to confirm your appointment. We have found that this helps reinforce your ability to remember that you have an appointment. Also, with proper notice, we are able to schedule patients on our waiting list into the cancelled appointment. Our Broken Appointment policy is as follows; First offense: you will be reminded of our policySecond offense: you will be charged as follows:25% of total fee for major procedures (crowns, bridges, root canals, implants ect.)50% of total fee for basic procedures (cleanings, fillings, impressions, denture ect.) 3. Third Offense: Dismissal from the practice We understand that unforeseen circumstances and emergencies may arise. When these situations occur, we ask that you contact our office as soon as you are able. We will review the occurrence and decide whether a broken appointment is warranted. We thank you in advance for your continued commitment to the quality of care we provide and we look forward to working together in the coming years.

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Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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