CHILD S INFORMATION PARENTS INFORMATION
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- Dora Dorsey
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1 104 E. Olive Ave., Suite 200 Redlands, CA Phone (909) Fax (909) WELCOME NEW PATIENT MEDICAL AND DENTAL HISTORY CHILD S INFORMATION Child s Name: Nickname: Date of Birth: Sex: Address: City: State: Zip: School: Grade: Hobbies/Interests Whom may we thank for referring you to our practice: PARENTS INFORMATION Parents Marital Status: q Married q Divorced q Separated q Single Parent 1 Name: Birthdate: Address: City: State: Zip: Home Number Work Number Cell Number Employer: Occupation: Preferred contact method: q q Text q Call q Mail Parent 2 Name: Birthdate: Address: City: State: Zip: Home Number Work Number Cell Number Employer: Occupation: Preferred contact method: q q Text q Call q Mail DENTAL INSURANCE INFORMATION Primary Insured Name: SSN: DOB: Ins. Company Name: Group Policy No: Ph. # Secondary Insured Name: SSN: DOB: Ins. Company Name: Group Policy No: Ph. # CHILD S MEDICAL HISTORY Child s Physician: Date of last visit: Reason for visit: Name of Practice: Phone #: Are Immunizations Current? q Yes q No Is your child under medical care at present? q Yes q No If Yes, please explain: Has Your Child had any of the following diseases or conditions? Please check off ALL that apply: q ADD/ADHD q CHRONIC SINUS INFECTIONS q HEART DISEASE q RHEUMATIC FEVER q ALLERGIES q CHRONIC EAR INFECTIONS q HEART MURMUR q SICKLE-CELL DIS/TRAIT q ANEMIA q CYSTIC FIBROSIS q HEART DEFECTS q TUBERCULOSIS q ANXIETY/DEPRESSION q SEIZURES/EPILEPSY q HEMOPHILIA q NEUROLOGICAL PROBLEMS q ASTHMA q DEVELOPMENTAL DELAY q KIDNEY PROBLEMS q ORTHOPEDIC PROBLEMS q AUTISM SPECTRUM q DIABETES q LIVER PROBLEMS q EYE PROBLEMS q BLEEDING DISORDER q DOWN SYNDROME q LUNG PROBLEMS q ACID REFLUX q CANCER q HIV/AIDS q PSYCHIATRIC TREATMENT q EMOTIONAL DISTURBANCES q CEREBRAL PALSY q HEPATITIS q SPEECH/HEARING PROBLEMS q ORAL/SENSORY INTEGRATION q CLEFT LIP/PALATE q MENTAL RETARDATION q BIRTH DEFECTS q HIGH BLOOD PRESSURE q LEARNING DISABILITY q PREMATURE BIRTH Does your child have any other diseases, conditions or syndromes not listed above? q Yes q No If Yes, please explain: Is your child allergic to any food or medicine? q Yes q No If Yes, please list: Page 1 of 2
2 CHILD S MEDICAL HISTORY (Continued) Is your child currently taking any medications? q Yes q No If Yes, please list: Has your child ever been sedated or had General Anesthesia? q Yes q No If Yes, what for? Has your child ever had surgery or been hospitalized? q Yes q No If Yes, please explain: Is your child having any difficulties in school? q Yes q No If Yes, please explain: Is there anything else we should know about your child? q Yes q No If Yes, please explain: Is there anything about your child you would like to discuss in private? q Yes q No DENTAL HISTORY Reasons for today s dental visit (check all that apply): q FIRST EXAMINATION q ROUTINE CHECK-UP q TOOTHACHE OR SWELLING q CAVITIES q APPEARANCE OF TEETH q CROWDING q ACCIDENT/INJURY Other: Has your child been to a dentist previously? q Yes q No When: Where: Were X-Rays taken: q Yes q No q Not sure If Yes, may we contact them to get copies? q Yes q No Does your child have any of the following habits? q THUMB/FINGER SUCKING q MOUTH BREATHING q PACIFIER q SNORING q LIP SUCKING/BITING q GRINDING/CLENCHING q BOTTLE/SIPPY CUP TO SLEEP What source of water does your child drink? q City Water q Bottled Water q Well Water Is your child breast fed or using a bottle/sippy cup? q Yes q No If No, what age did it stop? Child s typical eating pattern: q 2-3 meals/day q eats throughout the day Frequency of tooth brushing? times per day, flossing? times per day Who does the brushing? q Child q Parent/Guardian q Both What type of toothpaste does your child use? q Fluoride q No Fluoride q No Paste How would you describe your child s temperament? (Check ALL that apply) q OUTGOING q SHY q STUBBORN q ANXIOUS q FRIGHTENED q REGULAR KID q CURIOUS q MOODY q FRIENDLY q DEFIANT q ACTIVE q COOPERATIVE Has your child ever experienced any problems or complications due to dental care? q Yes q No If Yes, please explain: CONSENT The information I have given is correct to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes in my child s medical status and insurance benefits. I authorize Just For Kids Pediatric Dentistry to complete a Dental Evaluation, including Examination, X-Rays, Photographs, Cleaning and Fluoride Treatment when necessary as standard of care to properly diagnose and record any and all dental conditions. I authorize my insurance company to pay Just For Kids all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, including all late payment service charges. This consent is to remain in effect from the date indicated until cancelled in writing. Authorized signature Relationship to Child Date OFFICE USE ONLY SBE Prophylaxis required: q Yes q No Precautions: Summary: Caries Risk Assessment: q Low q Med q Hi Dr signature Date Page 2 of 2
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David L. Rothman, dds Pediatric Dentistry
Complete forms, print out and sign. Bring completed forms to your office visit. 1/7 pages Name: nickname: Sex: Male Female Birthdate: age: School: Is this your child s first dental visit? Yes No Is this
CHILD S REGISTRATION & HISTORY
SIMON P. MORRIS, D.D.S. MAI DINH D.D.S., M.S. CHILD S REGISTRATION & HISTORY Child s name FIRST MIDDLE LAST Nickname Date of birth Age Male Female Child s interests Pets Other children in family who are
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New Patient Packet. Patient Name: Today s Date: Last First MI. Preferred Name: Gender: Birth Date: Apartment Number
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INSURANCE INFORMATION
To provide the safest and most comprehensive dental care for your child, we ask for your cooperation in completing our detailed questionnaire. Date: Child s name: Nickname: Birthdate: Gender: M F Home
PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
Child Health and Dental History Form
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Child s Name: (First) (Middle) (Last)
Child s Name: (First) (Middle) (Last) Sex: M F Age: Birth date: / / Place of Birth: School: City: Pediatrician Name: Whom may we thank for referring you to our office? Name(s) of Sibling(s): WHAT IS YOUR
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Mother s Name: Birth date: SSN: Home Address: City State Zip Home Phone# Work # Cell # Address Employer
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PATIENT INFORMATION. Parent/Legal Guardian #1: Name: Date of Birth: / / Occupation/Employer: SS#: Work phone: Mobile: Home: address:
! PATIENT INFORMATION Your Child s Name: Nickname: Date of Birth: / / Age: Identifies Male: Female: School: Grade: Child s primary address: City: Zip: Telephone: Parent/Legal Guardian #1: Name: Date of
Patient Health History
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New Patient Registration Form
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Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment
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1. Tell Us About the Patient. 2. Legal Guardian #1 Information. Child s Name Last. Preferred name. Grade. Patient s Age. School. Patient s Birth Date
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Previous Dentist: Date of Last visit: Date of Last X ray:
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Today s Date We are so pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we ll be glad to help
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Today s Date / / Male Female. Child s Name Preferred Name. Child s Address City Zip. How were you referred to our office?
Today s Date / / Male Female Child s Name Preferred Name Child s Birthday / / Cell # ( ) - Home # ( ) - Child s Address City Zip How were you referred to our office? Who is accompanying this child today?
Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
Welcome Thank you for choosing us for your dental care needs. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to contact us. (206)
Healthy Smiles Start Here!
Patient s Information Last Name: First: Middle: Preferred Name: Gender: M or F Date of Birth: Age: SSN: Does the patient attend school: Yes or No. If yes, where? Child s physician: Phone #: Address of
Child Health/Dental History Form
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PERSONAL INFORMATION
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
YOUR CHILD'S PERSONAL INFORMATION. RESPONSIBLE PARTY (Person responsible for Child's Account)
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
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Just for Kids Pediatric Dentistry, Ltd. Patient Information
Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:
Patient Name Preferred Name Social Security. Address City, State, Zip. Home Phone Work Phone Cell Phone. Birth Date Age Driver s License #
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Responsible Party Information
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New Patient Information Name: : What name would you like to be called?: of Birth: Home Phone: Social Security No: Cell Phone: E-mail: Address: City: State: Zip: Employer: Work Address: City: State: Zip:
Our goal is to help your child reach and maintain good oral health and a beautiful smile that lasts a lifetime. I Name: 1 Billing Address:
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PATIENT INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
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Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
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HACKENSACK PEDIATRICS 1 of 5 MONA TANTAWI, MD, PC 177 SUMMIT AVENUE HACKENSACK, NJ Tel: ; Fax:
HACKENSACK PEDIATRICS 1 of 5 PATIENT REGISTRATION PATIENT INFORMATION Patient Name: Address: City, State: Zip Code: Today s Date: (mm/dd/yyyy) (mm/dd/yyyy) Gender: [ ] Male or [ ] Female Referred By: (i.e.:
PATIENT REGISTRATION PATIENT INFORMATION RESPONSIBLE PARTY INFORMATION FUN FACTS ABOUT ME! Primary Insurance Policy Holder Parent or Guardian
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Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
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HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance
HEALTH HISTORY FORM 4 How Did You Hear About Us? 5 Who is Accompanying the Child Today? Name Today s 1 2 3 Tell Us About Your Child Patient s Full Name Preferred Name Male Female Siblings We Treat Patient
PATIENT INFORMATION PARENT / GUARDIAN INFORMATION
PATIENT INFORMATION Child s name: Nickname: Age: Birth date: Male/ Female Names and ages of siblings: Home address: City/State/Zip: Telephone: Child s School: Child s Physician: Address & Phone Number:
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TODAY S DATE: Name: Birthdate: SSN: _Married _Single _Widowed _Divorced _Separated _Other. Address: Employer: Work Phone:
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Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
Today s Date: Name: Date of Birth: Residence: Street City Zip Code Home Phone Number Social Security: - - e-mail: Employment: Position Employer Work Phone Number Marital Status: (Please Circle) Single
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
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Conte See Oue Exei^ing
CoDcorcf %di^tvic D Dtisti?y 16 foundry Itreet, Co^corcf Conte See Oue Exei^ing nolttel Immediately off 1-93 at Exit 16 (see directions below) Please call our office for details. Direct Jons From North:
If you arrive minutes late for any appointment, you may be asked to reschedule your appointment for the next available appointment time.
APPOINTMENT POLICY A scheduled appointment is reserved specifically for your child. Any change in this appointment affects many people. We understand that circumstances change and an unexpected commitment
Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.
Welcome Date / / Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health. Patient s Name Last First M.I. Address City State Zip Code Home Phone
Patient Information. First Name: Middle Name: Last Name: Preferred Name: Address. Street: City: State: Zip Code: Home Phone: Work Phone: Cell Phone:
David B. Epstein DDS 1 0 0 1 M E D I C A L P L A Z A D R # 3 0 0, T H E W O O D L A N D S, T X 7 7 3 8 0 281-367- 3 0 8 5 d r e p s t e i n @ t h e w o o d l a n d s d e n t a l. c o m Patient Information
PATIENT INFORMATION AND MEDICAL HISTORY
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Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
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Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred
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NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. Insurance Co. Name Name
Health History Form Dr. Lisa LaPresti Today s Date: NOTE: The parent or Guardian who accompanies the child is responsible for payment at the time of service. 1. Tell Us About Your Child 5. Child s Name
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PATIENT REGISTRATION
Dr. Jaish J. Markos State License #053850 50 Dayton Lane Ste #103 Peekskill, NY 10566 Phone: (914) 402 6980 www.gckidsdmd.com PATIENT REGISTRATION Date 1. Tell Us About Your Child Child s First Name Middle
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JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD
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6101 Redwood Square Center Suite 300 Centreville, VA 20121 5047 Backlick Road Suite A & B Annandale, VA 22003 Health History Form Today s Date: NOTE: The parent or Guardian who accompanies the child is
Please complete entire form
Please complete entire form Patient Name: (Last) (First) (M) Address: City: State: Zip: DOB: Age: Sex: M F Social Security #: (If Using Insurance this is required) Home Phone: Cell Phone: Work Phone: Marital
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
Welcome to Tyler L. Smith Family Dentistry
Today s : Patient Information Welcome to Tyler L. Smith Family Dentistry Last: First: Middle Initial: _ Preferred: Address: City: State: Zip: Home #: Email: Cell #: Work #: Sex: Birth : Social Security
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
Primary Insurance Information
Durell Family Den-stry Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you.
Local Address: City State Zip. Permanent Address: City State Zip. Secondary Insurance Co: Insurance Phone: Policy #:
Patient Intake Form : Patient Name: (Last) (First) (M) Local Address: City State Zip Permanent Address: City State Zip Home Phone: Work Phone: Cell Phone: Birthdate: Age: Sex: M F Marital Status: Ethnicity:
Jane Otto Family Dentistry Gravois Road St. Louis, MO (314)
Jane Otto Family Dentistry 11521 Gravois Road St. Louis, MO 63126 (314) 842-2442 PATIENT INFORMATION Patient Name: Last First MI Male Female Married Single Child Other: Social Security #: Date of Birth:
Driver s License # Cell Phone Gender Male Female. Single Married Divorced Other. Driver s License # Cell Phone Gender Male Female
Patient Information: Patient Name Home Address City, State, Zip Home Phone Social Security # Birthdate Driver s License # Cell Phone Email Gender Male Female Work Phone Insurance Information: Marital Status
WELCOME TO SMILE BY DESIGN
WELCOME TO SMILE BY DESIGN Please tell us about yourself Name: Last First MI Title Preferred Name: Male Female Address: City: State: ZIP: SSN: DOB: Home Phone: Work Phone: Cell Phone: Email Address: Employer:
Acknowledgement of Receipt of Notice of Privacy Practices
HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good
PATIENT REGISTRATION & HISTORY
PATIENT INFORMATION Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT,
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: SINGLE
Jody Finazzo,dds, ms
Jody Finazzo,dds, ms Child & Adolescent Dental Specialist Dear Parent, Welcome to our practice! We appreciate the trust you have shown in us by selecting our practice to provide your child s dental care.
Glacier Dental 2421 E Tudor Road Suite #101 Anchorage, AK 99507
Patient Name: LAST FIRST MIDDLE INITIAL Gender: ( )MALE ( )FEMALE Marital Status:( )Married ( ) Single ( ) Child ( ) Other: Social Security #: - - Date of Birth: / / Address: City, State: Zip Code: Phone