Tell Us About Your Child

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Transcription:

GIVNG TREE PEDIATRIC DENTISTRY Rebekah Tannen DDS 110 Washington Avenue Pleasantville, NY 10570 Tel: 914-579-2225 Fax: 914-579-2226 Email: Team@givingtreedental.com www.givingtreedental.com We are thrilled to welcome you and your family and look forward to working with you to maintain your child s oral health. Please fill out this form as completely as possible. If you have any questions, we will be happy to help. Tell Us About Your Child Child s Name, M F Last first MI Nickname Child s Birthdate / / Age Address City State Zip Child s Favorite Activity/Music/TV Show/Video Game Does Your Child Play Sports? Yes No If Yes, What Sports Names and ages of Siblings How Did you Hear About the Office? (please list name) Pediatrician/Other Dentist School/Church/Synagogue Friend Insurance Company Google Yelp Local Newspaper Other Parent Information Mother s Information Name DOB: Occupation SS# Employer (name/address) Work Phone Home Phone Cell Phone Email address Preferred Method of Contact

Father s Information Name DOB: Occupation SS# Employer (name/address) Work Phone Home Phone Cell Phone Email address Preferred Method of Contact Who is accompanying the child today? Name Relationship Authorized Nanny/Sitter/ Au Pair In the event that I am unable to bring my child in for an appointment the following individuals have my permission to accompany my child and make any necessary decisions for my child s care. This includes consenting to any necessary treatment plan changes. Name: Relationship Contact Number The legal guardian must accompany their child/children for the first appointment. Insurance/Financial Information Name of Dental Insurance Company Telephone # of Insurance Company Policy Holder ID # Group # Annual Deductible Amount Annual Maximum *Most insurance reimburse 100% for preventative treatment and 50-80% for restorative and other advanced procedures. Please contact your insurance carrier directly for specifics. *First time patients, please bring your dental insurance card to the office or email copies of both sides in advance of the first appointment.

Dental History Reason for Today s Visit Is this your Child s first visit to the dentist? Yes No If not, who was the previous dentist Phone # When was your child s last exam? / / when were x-rays taken? / / If x-rays were taken please ask previous office to email records to team@givingtreedental.com Previous Dental Injury? / / Does your child require pre-medication prior to dental treatment? Yes No Has Your Child had a history of the following and if so when did they stop: Bedtime Bottle Fluoride Vitamins Pacifier Breast feeding Iron Supplements Teeth grinding Bottled water Mouth breathing Snoring Thumb sucking Finger sucking Fingernail biting Sleep Apnea Non-fluoridated water Other Habit Age stopped What Kind of multivitamin does your child use, if any? Chewable Liquid Drops Gummy None Does your child take a fluoride supplement prescribed by pediatrician or previous dentist? Yes No Do you brush your child s teeth or do they brush independently? Does your child use: Floss/Flossers Fluoride Rinse (ie ACT) None* *no worries we are here to teach your child the importance of flossing when indicated Child s Temperament Shy fearful Requires Special understanding Easygoing Calm Outgoing How do you think your child will act during dental treatment? How has your child s experience with other doctors been? Has your child had any previous negative dental experiences, if yes please explain Please list any additional questions or concerns you may have?

Health History Your Child s health is Excellent Fair Poor Child s Physician Phone # Date of last physical exam / / Ever been hospitalized overnight? Yes No When? Reason Vaccinations up to date? Yes No* *Giving Tree Dental is unable to accommodate patients who are not immunized. Our numerous patients with cancer history experience a severe immunocompromised status. Please speak with the doctor with any questions and they will be happy to speak with you. History of Surgery? Yes No Type of Surgery Does your child have any allergies (food/medications)? Yes No If yes, please list Has your child ever had any of the following conditions? Artificial bones/joints Artificial Heart Valve Asthma Arrhythmia Autistic Spectrum Disorder Abnormal Bleeding ADHD Anemia Blood Transfusion Cancer/Tumors Birth Defects Cleft Lip/Palate Crohn s Disease Congenital Heart Defect Cerebral Palsy Developmental Delay Diabetes Recurrent Ear Infections Hearing Loss Endocrine Function Issue Epilepsy/Seizures Eye/Vision Problems Fainting/Dizziness Glaucoma Gluten/Celiac Disease Glucose 6 Phos. Dehy. Def. Heart Murmur Hemophilia High/Low Blood Pressure HIV/AIDS Kidney Disease Liver/ Hepatitis Jaw Problems TMJ/TMD Jaundice Leukemia Lung Disease Lymphoma Metabolic Disorder Malignant Hyperthermia (or Family History) Milk Sensitivity (Casein/Lactose) Psychiatric Issues Rheumatic Fever Scarlet Fever

Speech Issues Sickle Cell Tuberculosis Thyroid Function Issue Tonsillitis Ulcerative Colitis ODD/OCD Other not listed Please List ALL medications and dosages your child takes I understand that the information I have given is correct to the best of my knowledge and that it will be held in the strictest of confidence. It is my responsibility to update the office of any changes to my child s medical status and current medications. I am the parent, guardian or personal representative of this child. There are no court orders in effect that prohibit me from signing consent for this child. I do herby request and authorize the staff at Giving Tree Pediatric Dentistry to preform necessary dental services for the child named in this document, including but not limited to x-rays and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is completed. I understand and agree that Dr. Tannen will make a courtesy evaluation of emergencies via cellular phone photos, should I (the parent/guardian) request this. I agree that communication may be made via secured email conversations between the doctor and myself (parent/guardian). Giving Tree Pediatric Dentistry will maintain the strictest measures to protect my family s privacy. Parent/Guardian s Signature Date Parent/Guardian Name Printed

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