Child Health/Dental History Form
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- Annis Newman
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1 Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M F Home Work Have you (the parent/guardian) or the patient had any of the following diseases or problems?... Yes 1. Active Tuberculosis, 2. Persistent cough greater than a three-week duration, 3.Cough that produces blood? If you answer yes to any of the three items above, please stop and return this form to the receptionist. No Has the child had any history of, or conditions related to, any of the following: Anemia Arthritis Asthma Bladder Bleeding disorders Bones/Joints Cancer Cerebral Palsy Chicken Pox Chronic Sinusitis Diabetes Ear Aches Epilepsy Fainting Growth Problems Hearing Heart Hepatitis Please list the name and phone number of the child s physician: HIV +/AIDS Immunizations Kidney Latex allergy Liver Measles Mononucleosis Mumps Pregnancy (teens) Rheumatic fever Seizures Sickle cell Thyroid Tobacco/Drug Use Tuberculosis Venereal Disease Other Name of Physician Phone Child s History Yes No 1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time? If yes, please list: 2. Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs? If yes, please explain: Is the child allergic to anything else, such as certain foods? If yes, please explain: How would you describe the child s eating habits? 5. Has the child ever had a serious illness? If yes, when: Please describe: Has the child ever been hospitalized? Does the child have a history of any other illnesses? If yes, please list: Has the child ever received a general anesthetic? Does the child have any inherited problems? Does the child have any speech difficulties? Has the child ever had a blood transfusion? Is the child physically, mentally, or emotionally impaired? Does the child experience excessive bleeding when cut? Is the child currently being treated for any illnesses? Is this the child s first visit to a dentist? If not the first visit, what was the date of the last dentist visit? Date: Has the child had any problem with dental treatment in the past? Has the child ever had dental radiographs (x-rays) exposed? Has the child ever suffered any injuries to the mouth, head or teeth? Has the child had any problems with the eruption or shedding of teeth? Has the child had any orthodontic treatment? What type of water does your child drink? City water Well water Bottled water Filtered water 22. Does the child take fluoride supplements? Is fluoride toothpaste used? How many times are the child s teeth brushed per day? When are the teeth brushed? Does the child suck his/her thumb, fingers or pacifier? At what age did the child stop bottle feeding? Age Breast feeding? Age 27. Does child participate in active recreational activities? NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Parent s/guardian s Signature Date For completion by dentist Comments For Office Use Only: Medical Alert Premedication Allergies Anesthesia Reviewed by Date American Dental Association, 2006 To Reorder call Form S707 or go online at
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4 Dental Arts By Lena Cosmetic and General Dentistry Lena J Salha, DDS 4041 Steck Ave. Austin, TX phone: Fax: Assignment and Authorization of Benefits I hereby give authorization for payment of insurance benefits to be made directly to Dental Arts By Lena, PC. for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In event of default, I agree to pay all costs of collection and reasonable attorney fees. I hereby authorize this Dental care Provider to release all information necessary to secure payment benefits. I further agree that a photocopy of this Agreement is as valid as the original. Authorization for E mail & Voic Usage for PHI I hereby give permission to leave a message on my voic concerning my personal dental health information I Agree with Option I Decline Option I hereby give permission to communicate, via e mail address listed on my patient information questionnaire, my personal dental health information I Agree with Option I Decline Option Patient Signature or Guardian signature if a minor Date Witness Signature Date
5 POLICY HOLDER AND INSURANCE INFORMATION Last Name: First Name: MI: Address: Apt#: City State Zip Home#: Work#: Cell#: Age: Sex: M F Date of Birth: Marital Status: SS#: Driver s License number: State: Employer s Name: Occupation: E- Mail Address: Preferred Pharmacy / Pharmacy phone #: EMERGENCY CONTACT NAME & PHONE NUMBERS: SPOUSE INFORMATION Name: Phone Numbers: Home: Cell: Work: Address: Apt#: City State Zip Age: Sex: M F Date of Birth: SS#: Employer s name: Occupation:
6 DENTAL INSURANCE INFORMATION PRIMARY DENTAL INSURANCE: Address: State/City/ Zip ID#: Policy# Name of policy Holder: Date of birth of policy Holder: SS# of policy Holder: Relationship to Patient: Patient Primary Care Doctor: Phone number: How did you learn about our office:
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please circle): Male Female Age: Date
More informationPatient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
More information----PATIENT INFORMATION---- Patient s Full Name Preferred Name DOB Age Sex. School Grade. Residence Address. City State Zip Home Phone #
Buckhead Pediatric Dentistry, LLC Pediatric and Adolescent Dentistry 3280 Howell Mill Road, NW Suite 230 Atlanta, GA 30327 404.351.PEDO (7336) general@buckheadpediatricdentistry.com ----PATIENT INFORMATION----
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Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
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5C Medical Park Drive Pomona, NY 10970 (845) 414-9626 drsmith@smithslittlesmiles.com www.smithslittlesmiles.com Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and
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More informationMedical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
More informationCreating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
More informationDate First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
More informationPatient Name Date of Birth / / Today s Date / /
Dr. Mark Valente Dr. Andy Indresano Board Certified, Fellowship Trained Phone. 972.707.0005 Fax. 888.992.6199 DISCspine.com New Patient Intake Form Name First MI Last Street Address Apt # _ City _ State
More informationChild s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:
Welcome Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their
More informationPATIENT HEALTH HISTORY
PATIENT HEALTH HISTORY Patient Name Today s Date Birthdate DENTAL HISTORY Reason for Today s Visit Are you having dental pain now? Former Dentist Date of last dental visit Last x-rays Check (!) if you
More informationEmployed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
More informationPatient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
More informationKingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
More informationGENERAL QUESTIONS CONTACT INFORMATION
GENERAL QUESTIONS Purpose of this visit: Today s date: Are you currently experiencing any dental pain? Date of last dental visit: Date of most recent dental x-rays: CONTACT INFORMATION Last Name: Telephone
More informationPatient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
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