Newton Street Dental, P.C.
488 Newton Street
South Hadley, MA 01075
(413) 538-9604
CHILD/ADOLESCENT REGISTRATION AND HEALTH HISTORY
PLEASE COMPLETE THE FOLLOWING CONFIDENTAL INFORMATION
Date: ______
Child’s First Name: ______M.I.: ______Last Name: ______
Nickname: ______Sex: M F Date of Birth: ______
Address: ______City: ______State: _____ Zip: ______
Home Phone: ______Parent Work/Cell: ______/______
School: ______Grade: ______Favorite Subject: ______
Referred to this office by: ______
Hobbies: ______Favorite Character: ______Sports: ______
FINANCIAL RESPONSIBILITY
Is your child covered by a dental plan? Yes No Have they received previous care with this plan? Yes No
Parent’s full name: ______Date of Birth: ______
Employed by: ______Occupation: ______
Name of Insurance Co.: ______ID #: ______
Parent’s full name: ______Date of Birth: ______
Employed by: ______Occupation: ______
Name of Insurance Co.: ______ID #: ______
CONSENT: I hereby authorize this dental office to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctors to make a thorough diagnosis of the patient’s dental needs. I also authorize the doctors to perform any and all forms of treatment, medication, and therapy that may be indicated. I authorize and consent that the doctors may choose such assistance as deemed fit. I understand that the use of anesthetic agents embodies a certain risk. I understand that the responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand that a 1.5% finance charge (18% annually) will be added to any balance over 60 day.
PATIENT OR RESPONSIBLE PARTY SIGNATURE ______DATE ______
RELATIONSHIP TO PATIENT______
MEDICAL HISTORY
Child’s Physician: ______Phone #: ______
Yes No
1. Is your child under the care of a physician for any medical problem?
What? ______
2. Is you child currently taking any medication?
What? ______
3. Has your child ever been hospitalized or had surgery?
For what? ______
4. Is your child allergic to any food or medicine?
What? ______
5. Has your child had a history of: (please √)
Heart Trouble or Murmurs Headaches Kidney/Liver Involvement Autism
Rheumatic Fever Brain Injury Speech Delay Hepatitis
Latex Allergy Diabetes Bleeding Problems Asthma
Taking Birth Control Developmental Delay Allergies Epilepsy
Blood Disorders Drug Sensitivity Seizures/Convulsions Ear Pains
Thyroid Condition Anxiety Depression Cancer
Other ______
DENTAL HISTORY
Is this your child’s first dental visit? Yes No Previous Dentist______
Phone #:______Date of last visit: ______Date of last x-ray: ______1. Any injuries to your child’s teeth or jaw? (falls, blows, chips, etc.) Yes No
Explain ______
2. History of: (please √)
Thumb sucking Lip sucking Finger sucking Nail Biting Pacifier
3. How do you think your child will act toward dentist?
______
4. How often does your child brush? ______Floss? ______Supervised Y N
5. Does your child receive: (please √) Fluoride in vitamins Fluoride tablets/drops Fluoridated water None
To the best of my knowledge, all of the information on both sides of this form is true and correct. If there is any change in my health, or my medications, I will inform the doctor prior to any treatment. I authorize treatment for the person named above and agree to pay all fees and charges for such treatment. I understand that Newton Street Dental, PC will use my health history information as necessary for diagnosis or treatment.
PATIENT OR RESPONSIBLE PARTY SIGNATURE ______DATE ______
RELATIONSHIP TO PATIENT______