Child Patient Information

Child Registration Form - Dental
* required field

Patient Information

Parent/Guardian Information

Secondary Phone Number


Secondary Phone Number

Emergency Contact

Insurance Information

Dental History

How did you hear about our Practice?
Has your child's tonsils or adenoids been removed?*
Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?*
Does your child you have any missing or extra permanent teeth?*
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?*
Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?*

Does your child have any allergies/sensitivities to medications or latex?*
Is your child currently taking any prescription or over-the-counter medications?*
Has puberty and/or menstruation begun?*
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?*
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?*

Check if your child has or have ever had any of the following:


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

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