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?*YesNoDate of last visit to a dentist* MM DD YYYY For what service?*Has child complained about dental problems?*YesNoPlease describe dental problems here:*Any unhappy dental experiences?*YesNoPlease describe the unhappy dental experiences so we can better serve you:Any unusual mouth habits?*YesNoPlease describe those habits:*Any orthodontic appliances worn now or ever before?*YesNoWhat orthodontic appliances?*Is fluoride taken in any form*YesNoHealth HistoryDoes child have a physician?*YesNoChild’s Physician* Mr.Mrs.Ms.Dr. Prefix First Last Physician's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*YesNoIs child receiving any medication or drugs?*YesNoPlease describe below:*Is there excessive bleeding when cut?*YesNoSelect 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 InformationSchoolGradeFather's NameMother's NameResidence Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Father Employed ByFather Work PhoneMother Employed ByMother 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 ChildAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*YesNoName of Dental Insurance Carrier*Through what Company/Employer*Group Number*Parent/ Guardian Signature*Parent/ Guardian Name* First Last Date* Date Format: MM slash DD slash YYYY Thank You
