Child Registration This personal information will help us to give the most consideration of your time and feelings. It is important to have complete answers. All information is, of course, confidential.Child's Name* First Last Child's Age*Please enter a number from 1 to 17.Birth Date* MM DD YYYY Dental HistoryHas child previously been to the dentist?* Yes No Date of last visit to a dentist* MM DD YYYY For what service?*Has child complained about dental problems?* Yes No Please describe dental problems here:*Any unhappy dental experiences?* Yes No Please describe the unhappy dental experiences so we can better serve you:Any unusual mouth habits?* Yes No Please describe those habits:*Any orthodontic appliances worn now or ever before?* Yes No What orthodontic appliances?*Is fluoride taken in any form* Yes No Health HistoryDoes child have a physician?* Yes No Child’s Physician* Mr.Mrs.Ms.Dr. Prefix First Last Physician's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician's Primary Phone*Date of last exam* MM DD YYYY Is child under care of physician now?* Yes No Is child receiving any medication or drugs?* Yes No Please describe below:*Is there excessive bleeding when cut?* Yes No Select if child is allergic to any of the following:* Penicillin or other drugs Food Pollen Animals Dust NONE OF THE ABOVE APPLY If yes, please describe*Has child any history of or difficulty with any of the following:* Anemia Asthma Bladder Cerebral Palsy Chicken Pox Chronic Sinus Convulsions Diabetes Epilepsy Fainting Hearing Headaches Heart Immune Deficiency Kidney Liver Malignancies Mastoid Measles Mononucleosis Mumps Rheumatic Fever Thyroid Tuberculosis Hepatitis Other NONE OF THE ABOVE APPLY If you chose other, please describe here:Please describe any current medical treatment including drugs, pending surgery, recent injuries or any other information I should be aware of that we have not discussed:Child's Personal InformationSchool Grade Father's Name Mother's Name Residence Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Father Employed By Father Work PhoneMother Employed By Mother Work PhoneFather's Birth Date MM DD YYYY Mother's Birth Date MM DD YYYY Person Financially Responsible (if other than parent) First Last Relationship to Child Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneWhom may we thank for referring you? Insurance InformationDo you have insurance for your child?* Yes No Name of Dental Insurance Carrier* Through what Company/Employer* Group Number*Parent/ Guardian Signature*Parent/ Guardian Name* First Last Date* MM slash DD slash YYYY Thank You Δ