MotherStepmotherGuardian

Marital Status
SingleMarriedWidowedSeparatedDivorced

FatherStepfatherGuardian

Marital Status
SingleMarriedWidowedSeparatedDivorced

Your Childs Overall health as well as any medications which your child takes could have an important interrelationship with the dental care your child recieves. Please answer each of the following questions completely.

Is your child's water fluoridated?
YesNo

Does your child take fluoride supplements?
YesNo

Suck Thumb/Finger
YesNo

Suck/Bite Lip
YesNo

Bite/Chew Nails
YesNo

Chew Hard Objects(pencils,etc.)
YesNo

Grind Teeth
YesNo

Clench Jaws
YesNo

Date of last Dental visit

Previous Dentist

Address

Has your child had difficulty with previous dental visits?
YesNo

Has your child ever taken Fen-Phen/Redux?
YesNo

Asthma
YesNo

Handicaps/Disabilities
YesNo

Cancer
YesNo

Tuberculosis
YesNo

Hepatits
YesNo

Diabetes
YesNo

HIV/AIDS
YesNo

Rheumatic Fever
YesNo

Hemophilia
YesNo

Congenital Heart Defect
YesNo

Abnormal Bleeding
YesNo

Heart Murmur
YesNo

Stomach, Liver or Kidney Problems
YesNo

Convulsions/Epilepsy
YesNo

A persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)
YesNo

Is your Child taking any medications
YesNo

(If yes, please list)

Does your child have a history of allergies/senstivities/adverse reactions to any drugs or medications (Penicillin, Novocain, etc.)?
YesNo

(if yes,please describe)

Does your child have a history of allergies to any other substances(latex, environment, etc.)?

Please explain any medical problems that your child has

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
CashCheckVISAMaster CardDiscoverI wish to discuss the office payment policy

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility CO inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services 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 care to third party payers and/or tithe health practitioners. I authorize and request my insurance company to pay directly to the dentist or dentist's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Patient(parent/Guardian if minor)

Date

Signature of Dentist

Date