Patient Registration Form

Child’s Name: _____________________________________ Soc. Sec. #: _______________________________

Sex: Male ___ Female ___ Birth date: _________________ ______________ ________________________

Month Day Year

Parents’ Name: __________________________________________ Home Phone: _______________________

Address: ______________________________ ____________________ ____ ______________________

Street Address City State Zip

Email Address: _____________________________________________________________________________

Person Responsible For Payment Of Account In Addition To Parents: ____________________________________

Father Employed By: ________________________________________ Phone: __________________________

SSN: _____________________ ________ ________________________ Date of Birth: __________________

Mother Employed By: ________________________________________ Phone: _________________________

SSN: _____________________ ________ ________________________ Date of Birth __________________

If self-employed, please state business: ___________________________________________________________

Who referred you to this practice? ______________________________________________________________

Dental Insurance Program: _________________________________ _________________________________

Primary Secondary

Group #: ___________________________________________ Policy Holder: ___________________________

Child attends what school? _____________________________________________________________________

Medical History

Is child in good general health? Yes / No

Has child had any illnesses recently? Yes / No

Is child taking any medications at this time? Yes / No

Has child ever been hospitalized? Yes / No

Does child have any heart defect or other heart problems? Yes / No

Has child had Rheumatic Fever? Yes / No

Has child ever had a kidney infection? Yes / No

Is child allergic to any medicines? If yes, which ones? ________________________________________ Yes / No

Does child have any other allergies? If yes, please describe. ____________________________________ Yes / No

Has child ever had hepatitis? Yes / No

Has child experienced excessive bleeding from a cut or scratch? Yes / No

Please state any other facts about the child’s medical condition that is not described above.

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Dental History

Who is your family dentist? _____________________________________________________________________

When was the child’s last dental appointment? _______________________________________________________

When were last x-rays taken? ___________________________________________________________________

How often does the child brush his/her teeth? ________________________________________________________

Are there any other dental concerns? ______________________________________________________________

Is child complaining of any conditions involving the mouth? If so, please describe. ____________________________

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Is child taking a fluoride supplement or fluoride vitamin? Yes / No

Has child had topical fluoride treatment? Yes / No

Does child brush teeth with parental supervision? Yes / No

Does child have any harmful oral habits? If so, please describe. Yes / No

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Has child had a frightening or unpleasant dental experience? If so, please describe. Yes / No

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What have you told your child about the scheduled dental appointment? _____________________________________

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Permission for Treatment and Responsibility for Payment

I, being the parent or guardian of the above minor patient, do hereby authorize and request performance of dental

services for this patient, and further, the performance of any procedures the judgment of the doctor may deem necessary

during the performance of any operation. This includes treatment in the dental office as well as for outpatient care if

necessary.

I also authorize the administration of anesthetics or analgesics which may be deemed advisable by the doctor.

Furthermore, I will be responsible for any financial obligations incurred on this child for dental treatment. I understand

that payment must be made at the time services are rendered unless other financial arrangements have been made. I

also agree to be responsible for the 15.00 collection fee for any returned checks and reasonable attorney fees if my

account becomes delinquent and legal action for its collection is required.

Date: __________________________ Signature: _________________________________________________

Witness: __________________________________________ Relationship: _____________________________