Patient Information and Health History "*" indicates required fields Step 1 of 8 12% Child's Name*Child's Nickname*Child's D.O.B.* MM slash DD slash YYYY Male or Female* Male Female Home Address*Home Phone* Responsible Party(1)*Responsible Party(1)* Mother Father Guardian Other Responsible Party (1) Work Phone*Responsible Party (1) Cell Phone*Responsible Party(1) Employer*Responsible Party(1) Occupation*May we text you?*NoYes Responsible Party(2)Responsible Party(2) Mother Father Guardian Other Responsible Party (2) Work PhoneResponsible Party (2) Cell PhoneResponsible Party(2) EmployerResponsible Party(2) OccupationMay we text you?NoYes EMERGENCY CONTACT (other than parent/guardian)*Relationship to Child*Emergency Phone*OTHER SIBLINGS*Write None if child has no other siblings.HAVE THEY BEEN SEEN IN OUR OFFICE?*NoYes Dental InsurancePrimary CarrierSubscriberSSN and/or ID NumberD.O.B. Dental InsuranceSecondary CarrierSubscriberSSN and/or ID NumberD.O.B. Medical InformationChild’s Medical Physician/Pediatrician*Location of Office*Please list any current ALLERGIES*Please list any current MEDICATIONS*Conditions Asthma Heart Problems Difficulty Hearing Speech Impediment Developmental Delays Any Medical or Emotional Disturbance Cerebral Palsy Liver or Kidney Disease Seizures Convulsions Fainting Spells Diabetes Hepatitis Sickle Cell Anemia Tuberculosis Bleeding Problems Immune System Disorders Select AllMedical DiagnosisSBE (pre-meds) required*YesNoIf so, pharmacy name and phone numberIf Asthma, has your child been seen in the emergency room?*Not ApplicableYesNoWhen?What triggered reaction?Inhaler needed?Not ApplicableYesNoImmunization status:*Current, Past Due, Other?Hospitalizations/Surgeries:Date of Last Dental Exam: MM slash DD slash YYYY DentistLocationHas there been any injury to the teeth, head or neck since the patient’s last cleaning and is there any condition/problem you wish to bring to the doctor’s attention?*NoYesIf so, Please ExplainReferred By? READ THE APPOINTMENT POLICY Click Here READ THE FINANCIAL POLICY Click HereToday's Date MM slash DD slash YYYY Electronic Signature*CAPTCHA
