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 History
Has 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 History
Does child have a physician?*
- Yes
- No
Child’s Physician*
Prefix First Last
Physician's Address*
Street Address Address Line 2 City 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 Information
School
Grade
Father's Name
Mother's Name
Residence Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Father Employed By
Father Work Phone
Mother Employed By
Mother Work Phone
Father'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 State ZIP Code
Phone
Whom may we thank for referring you?
Insurance Information
Do 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

Dental History

Health History

Child's Personal Information

Insurance Information

Links