We are pleased to welcome you to our practice. Please complete this form. The following information is necessary to enable us to provide your child with the best dental care possible. All information disclosed is confidential and shall only be used for dental and medical purposes.
Date of Birth
Parent's Marital Status:
Click here to selectSingleMarriedWidowedDivorcedSeparated
Who has legal custody of the child (if applicable):
Click here to selectMotherFatherJointOtherN/A
Is patient a foster child?
Click here to selectYesNo If yes, please provide court documents.
Contact Person in case of Emergency:
Date of last physical exam:
Is patient in good health?
Click here to selectYesNo
Has patient ever had health problems/been hospitalized?
Is patient currently taking any medication?
Have you ever been told that patient needs antibiotics before dental treatment?
Does patient have any food allergies?
Does patient have any allergies to meditation?
Is patient allergic to latex?
Does patient have any other allergies?
ArthritisAsthma DiabetesGI Disorder Heart Disease Kidney Disease Rheumatic FeverADHD Anxiety/Nervousness AutismEmotional Disability Learning Disability Behavior Issues Psychiatric DisorderHepatitis HIV Infection TuberculosisAnemiaBleeding (Prolonged) HemophiliaBrain InjuryCerebral PalsyCleft Lip/Palate Developmental Delay Eating Problems Growth Problems SeizuresSpeech Problems Hearing Loss Neuromuscular Defect Orthopedic ProblemsCancerLeukemiaFainting/HeadachesGag ReflexSleep ApneaSleep ProblemsSnoring
Is this the patient's first visit to the dentist?
If no, when was the last visit?
Please check any of the following that may describe the patient's attitude towards dentistry:
Does patient have any of the following habits?
Nursing bottleNail bitingPacifier suckingThumb/Finger suckingTeeth grindingCheek/Lip bitingJaw ClenchingMouth breathing
Has the patient had local anesthesia (Novocain)?
Does the patient brush his/her teeth?
Do you assist in brushing the patient’s teeth?
Does the patient use dental floss?
Does the patient use fluoride in any form?
Does the patient have sugar snacks? (e.g. raisins, fruit rollups, candy, etc.)
Does the patient drink soda and/or juice?
Please leave this field empty.