Growing healthy smiles pediatric dentistry

Child’s Name (first / mi / Last)

Birthdate MM/DD/YYYY

Birthdate MM/DD/YYYY

Address Street / ZIP

Email

Phone

Father's Name

FatherStepfatherOther

MarriedDivorcedSingle

Address City

Address Street / ZIP

Social Security

Birthdate MM/DD/YYYY

Employer (name of business)

Occupation

Dental insurance CO:

Subscriber #

Address street/city/state/zip

Group #

Email

Phone

Father's Name

motherstepmotherOther

MarriedDivorcedSingle

Address City

Address Street / ZIP

Social Security

Birthdate MM/DD/YYYY

Employer (name of business)

Occupation

Dental insurance CO:

Subscriber #

Address street/city/state/zip

Group #

Name of Insured

Birthdate MM/DD/YYYY

Relation to child?

Address street/city/state/zip

Dental Insurance

Social Security #

Address street/city/state/zip

Subscriber #

What is the purpose of today’s visit? (describe)

Who is your child’s physician?

Address street/city/state/zip (if known)

Whom can we thank for referring you?

Address street/city/state/zip (if known)

Select One

Describe if yes

List medications

Describe if yes

Describe if yes

( If not presently, at what age did the habit stop? )

What is your child’s primary source of water?

name of Water company

Does your child have a history of the following:

List

List

Describe

Describe

Describe

Any additional information about your child we should know?

I, being the parent/guardan, custodian of the above minor, do hereby authorise such dental care, incloding the use of local anesthetics and nitrous oxide/oxygen analgesia, and other medications as the judgement of the dentist may dictate.

Signature

Date