Tell Us About Your Child

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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 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 q M q F Last First MI Nickname Child s Birthdate / / Age Address City State Zip Does Your Child Play Sports? q Yes q No If Yes, What Sports How did you hear about our Office? (please list name) q Pediatrician/Other Dentist q Friend q School/Church/Synagogue q Google q Yelp q Local Newspaper q NY Metro Parents Magazine q NY Metro Parents Website q Other Mother s Information Name DOB / / Occupation SS# - - Employer (name/address) Cell Phone Home Phone Work Phone Email Preferred Method of Contact: q Text Message q Email q Cell Phone q Work Phone q Home Phone

Father s Information Name DOB / / Occupation SS# - - Employer (name/address) Cell Phone Home Phone Work Phone Email Preferred Method of Contact: q Text Message q Email q Cell Phone q Work Phone q Home Phone 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 # *First time patients, please bring your dental insurance card to the office or email copies of both sides in advance of the first appointment. Policy Owner s Name Relationship to Patient Policy Owner s Birthdate Social Security # Policy Owner s Employer

Health History Your Child s health is q Excellent q Fair q Poor Child s Physician Phone # Date of last physical exam / / Has your child ever been hospitalized overnight? q Yes q No When? Reason for hospitalization Vaccinations up to date? q Yes q No History of Surgery? q Yes q No Type of Surgery Does your child have any allergies to food? q Yes q No If yes, please list Does your child have any allergies to medicine? q Yes q No If yes, please list Has your child ever had any of the following conditions? q Asthma q Autism Spectrum Disorder q ADHD q Heart Murmur q Congenital Heart Defect q Arrhythmia q Epilepsy/Seizures q Artificial Heart Valve q Cancer/Tumors q Leukemia q Lymphoma q Sickle Cell q Artificial bones/joints q Recurrent Ear Infections q Cleft Lip/Palate q Developmental Delay q Birth Defects q Glaucoma q Thyroid Function Issue q Cerebral Palsy q HIV/AIDS q Blood Transfusion q Abnormal Bleeding q Hemophilia q Endocrine Function q Issue Fainting/Dizziness q Lung Disease q Crohn s Disease q High/Low Blood Pressure q Hearing Loss q Ulcerative Colitis q Liver/ Hepatitis q G6PD q Gluten/Celiac Disease q Diabetes q Anemia q Kidney Disease q Jaundice q Tuberculosis q Other not listed Please List ALL medications your child takes, their dosages and frequency

Dental History Reason for Today s Visit Is this your child s first visit to the dentist? q Yes q 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 drsmith@smithslittlesmiles.com Has your child had any previous dental injury? q Yes q No If yes, when? / / Does your child require pre-medication prior to dental treatment? q Yes q No Has your child had a history of the following and if so when did they stop: q Bedtime Bottle q Fluoride Vitamins q Pacifier q Breast Feeding q Iron Supplements q Teeth Grinding q Bottled Water q Mouth Breathing q Snoring q Thumb Sucking q Finger Sucking q Fingernail Biting q Sleep Apnea q TMJ q Other Habits Age Stopped What Kind of multivitamin does your child use, if any? q Chewable q Liquid q Drops q Gummy q None Does your child take a fluoride supplement prescribed by a pediatrician or a previous dentist? q Yes q No Do you brush your child s teeth or do they brush independently? Does your child use: q Floss/Flossers q Fluoride Rinse (ie ACT) Has your child had any previous negative dental experiences? q Yes q No If yes, please explain Please list any additional questions or concerns you may have

HIPAA Privacy Practices Notification I, the undersigned parent/legal guardian of, have been issued the HIPAA Notice of Privacy Practices. I fully understand that the Practice is required by law to maintain the privacy of my child's medical and health information. I acknowledge that the Practice will use and disclose my child's health information for the purposes of treating my child, obtaining payment for services rendered to my child and conducting health care operations. Authorization and Release To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk. Furthermore, I understand that it is my responsibility to inform this dental office of any changes in my child s medical status. I authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such dental care to third party payors and/or other health practitioners as necessary. I hereby authorize the Dr. Marita Smith or any other doctor employed by Smith s Little Smiles to perform the examination and after explanation, any and all treatment for the above named child including radiographs if indicated and consent to such methods, drugs and agents that may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that, as a condition of my child's treatment by this office, financial arrangements must be made in advance. Parent/Guardian s Signature Parent/Guardian Name Printed Date

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