Patient's Name *

First Name

Last Name

Patient's Birth Date *

MM

DD

YYYY

Gender *

Male

Female

Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Alternate Parent's Phone Number *

(###)

###

####

Alternate Parent's Name *

First Name

Last Name

Responsible Party's Name/Guardian *

First Name

Last Name

In case of emergency (someone that does NOT live with child) *

First Name

Last Name

In Case of Emergency Phone *

(###)

###

####

Policy holder's name *

First Name

Last Name

Policy holder's DOB *

MM

DD

YYYY

Policy holder's address (if different from child)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy holder's phone number *

(###)

###

####

Insurance Phone Number *

(###)

###

####

Patient's Name *

First Name

Last Name

Parent's Marital Status

Married

Separated

Divorced

Single

Is your child adopted?

yes

no

If yes, do you have legal documentation?

yes

no

Pediatrician's Phone Number: *

(###)

###

####

Mom's Dental Health

Good

Fair

Poor

Dad's Dental Health

Good

Fair

Poor

Does your child play contact sports?

yes

no

If so, do they wear a mouth guard?

yes

no

Does your child brush his/her own teeth?

yes

no

Does your child use dental floss?

yes

no

Are your currently nursing your child?

yes

no

Does your child use fluoride products?

Rinses

Gels

Drops

Tablets

Toothpaste

Has your child had problems with any of the following (please check all that apply)

Cavities

Toothaches

Bad Breath

Bleeding Gums

Color of teeth

Gum Infection

Grinds Teeth

Appearance of teeth

Teeth sensitive to hot/cold

Teeth sensitive to sweets

Teeth bumped/chipped

Alignment of teeth

Habit - pacifier

Habit - finger/thumb

Other