CHILD’S
REGISTRATION
AND HISTORY
TODAY'S DATE:______
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CHILD’S NAMECHILD’S SOCIAL SECURITY NUMBER
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RESIDENCE ADDRESSPHONE
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CITYSTATEZIP CODEDATE OF BIRTH
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FATHER’S NAME BUSINESS PHONE
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FATHER EMPLOYED BYCELL/MOBILE BUSINESS PHONE
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POSITIONHOW LONGPREFERRED EMAIL ADDRESS
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MOTHER’S NAME
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MOTHER’S EMPLOYERBUSINESS PHONE
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POSITIONHOW LONG
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WHO IS RESPONSIBLE FOR PAYMENT? (PARENTS, GUARDIAN, OTHER)
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DENTAL INSURANCE CARRIER GROUP/POLICY NUMBER
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DENTAL INSURANCE ADDRESS
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INSURED EMPLOYEE (MOTHER OR FATHER)FATHER’S SOCIAL SECURITY NUMBER
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MOTHER’S SOCIAL SECURITY NUMBER
WHOM MAY WE THANK FOR REFERRING YOU?______
DENTAL HISTORY
IS THERE ANYTHING ABOUT THE CHILD’S MOUTH THAT CONCERNS YOU NOW?______
HOW LONG HAS IT BEEN SINCE CHILD HAS SEEN A DENTIST?______
WHAT WAS DONE THEN?______
DID CHILD HAVE XRAYS?______
HOW OFTEN DID CHILD VISIT BEFORE THAT?______HAS CHILD LOST ANY TEETH?______
WHERE IN MOUTH?______WHY WERE THEY LOST?______
DID CHILD HAVE THEM REPLACED?______DID ANYONE RECOMMEND REPLACEMENT?______
HAS CHILD EVER HAD A ROOT CANAL?______HAS CHILD EVER HAD BRACES?______
HOW DOES CHILD TAKE CARE OF HIS/HER TEETH?______
DO CHILD’S GUMS EVER BLEED?______
DO YOU FEEL CHILD HAS AN UNPLEASANT BREATH AT TIMES?______
DOES CHILD HAVE AN UNPLEASANT TASTE IN YOUR MOUTH?______
MEDICAL HISTORY
IS CHILD UNDER CARE OF PHYSICIAN NOW?______
IS CHILD TAKING ANY MEDICATION NOW? ______IS CHILD USING ANY DRUGS?______
PHYSICIANS NAME ______
PHYSICIANS ADDRESS ______
PHYSICIANS PHONE NUMBER______
HAS CHILD EVER HAD SURGERY/ EVER BEEN HOSPITALIZED?______IF YES, WHY?______
DOES CHILD HAVE EARACHES?______
ARE THERE ANY EMOTIONAL PROBLEMS?______
DOES CHILD HAVE ANY FEARS ABOUT DENTISTRY? ______WHAT ARE THEY?______
WHAT CAN WE DO TO MAKE CHILD COMFORTABLE? ______
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HOW DO YOU AND CHILD FEEL ABOUT CHILD’S TEETH?______
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APPEARANCE / RECOGNITION / COMFORT / SELF-PRESERVATION / INVESTMENT
MANY MEDICAL CONDITIONS MAY AFFECT THE TREATMENT WE CAN DO FOR YOU. HAVE YOU HAD ANY OF THE FOLLOWING?
_____ Heart Condition_____ Bladder_____ HIV Test
_____ Mumps_____ Diabetes_____ Kidney Condition
_____ Mononucleosis_____ Hepatitis_____ Liver Condition
_____ Circulatory (blood) Condition_____ Rheumatic Fever_____ Tuberculosis
_____ Cancer _____ Sinus Condition_____ Venereal Disease
_____ Asthma_____ Stroke_____ Thyroid
_____ Anemia_____ Psychiatric Care_____ Nervous Condition
_____ Chicken Pox_____ Convulsions_____ Epilepsy
_____ Measles
ALLERGIES TO: DRUGS______ANESTHETICS______
FOOD ______OTHER ______
PLEASE DESCRIBE ANY CURRENT MEDICAL TREATMENT INCLUDING DRUGS, PENDING SURGERY, RECENT INJURIES OR ANY OTHER INFORMATION I SHOULD BE AWARE OF THAT WE HAVE NOT DISCUSSED.
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- I HAVE REVIEWED THE ABOVE QUESTIONS AND INFORMATION AND CERTIFY IT TO BE TRUE TO THE BEST OF MY KNOWLEDGE.
- PLEASE NOTE: 48 HOURS (24 BUSINESS HOURS) NOTICE ARE REQUIRED TO AVOID CHARGE FOR CANCELED OR BROKEN APPOINTMENTS.
- I AGREE TO PAY ALL BALANCES DUE, IN FULL, AT THE TIME OF SERVICE, UNLESS OTHER WRITTEN ARRANGEMENTS ARE MADE.
SIGNATURE ______