Pediatric Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Tell us about your child

Patient Name :
	*Last Name :	Middle Name :	*First Name :

Nickname :

*Date of Birth :
Age:
Sex :	Male Female

School :
Grade :
SSN :
*Home Phone :	( )- -

*Home Address
City :
State :
Zip :
APT# :

*Email address :

Who is accompanying the child today?

His / Her Name :
Relationship :
Do you have legal custody of this child? Yes No

How did you hear about us?
Have you visited our website? Yes No
Whom may we Thank for referring you?
Other family members seen by us :
Previous / Present Dentist:
Last visit date :

Parent’s marital status:	Single Married Partnered Divorced Separated
	Widowed

Mother’s information: Step mother Guardian
Name :
Birthday :
Work Phone:	( )- - -
Home Phone:	( )- -
Employer :
SSN:

Father’s information: Step father Guardian
Name :
Birthday :
Work Phone:	( )- - -
Home Phone:	( )- -
Employer :
SSN:

Person responsible for account

Name :
Relationship :

Billing address :
City :
State :
Zip :
APT# :

Home Phone:	( )- -
Work Phone:	( )- - -
Employer :
Driving license :
SSN:

Who is responsible for making appointments?

Name :
Home Phone:	( )- -
Work Phone:	( )- - -

Insurance information

Primary insurance
Dental coverage?	Yes No
Insurance Co.:
SSN:

Address:
City :
State :
Zip :

Phone :	( )- -
Group# :
Insured’s name :
Relationship :
Birthday :
Insured’s ID :
Insured’s employer

Employer Address:
City :
State :
Zip :
APT# :

Secondary insurance
Dental coverage?	Yes No
Insurance Co.:
SSN:

Address:
City :
State :
Zip :

Phone :	( )- -
Group# :
Insured’s name :
Relationship :
Birthday :
Insured’s ID :
Insured’s employer

Employer Address:
City :
State :
Zip :
APT# :

Why did you bring your child to the dentist today?

Has the child ever had a serious / difficult problem associated with previous dental work?	Yes No
Is the child’s water fluoridated?	Yes No
Is the child taking fluoridated supplements?	Yes No
Has the child ever had any pain/tenderness in his/her jaw joint (TMJ / TMD)?	Yes No
Does the child brush his/her teeth daily?	Yes No
Floss his/her teeth daily?	Yes No
Is the child currently under the care of a physician?	Yes No

Child’s physician :
Telephone :	( )- -
Last visited on:

Please describe the child’s current physical health: Good Fair Poor
Is your child allergy to Nuts?	Yes No
Has the child had any traumatic experiences at the dental office?	Yes No
Does the child have a specific fear about going to the dental office?	Yes No

Please list all drugs that the child is currently taking :

Please list all drugs / materials that the child is allergic :

Latex?

Yes No

Metals / Nickel?

Yes No

Plastic?

Yes No

Has the child ever had any of the Following medical problems?
Yes No	Abnormal bleeding	Yes No	ADD / ADHD
Yes No	Allergies to any drugs	Yes No	Any hospital stays
Yes No	Any operations	Yes No	Artificial Bones / Joints / Valves
Yes No	HIV+ / AIDS	Yes No	Asthma
Yes No	Cancer	Yes No	Congenital heart defect
Yes No	Convulsions / Epilepsy	Yes No	Diabetes
Yes No	Handicaps / Disabilities	Yes No	Hearing impairment
Yes No	Heart murmur	Yes No	Hemophilia
Yes No	Hepatitis	Yes No	Kidney / Liver problems
Yes No	Rheumatic / Scarlet fever	Yes No	Sickle cell disease / traits
Yes No	Tuberculosis (TB)

Please discuss any serious medical problems that the child has had :

Does/Did the child have any of the following habits?
Yes No	Lip sucking / Biting	Yes No	Nursing bottle habits
Yes No	Nail biting	Yes No	Thumb / Finger sucking
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Neighbor or relative not living with you.

Name :
Home Phone:	( )- -

Address :
City :
State :
Zip :
APT# :


*	If deemed advisable, I grant permission for our physician to be contacted for details and advice. For evaluation or teaching purposes I authorize the taking of radiographs, photographs, or other diagnostic measures appropriate for a thorough evaluation. Authorization is also given for dental treatment to be rendered by the dentist and office staff, and I will assume financial responsibility.


*Signature of Parent or Guardian	Date

Carmen S.
My family and I have been patients for many years. The entire team is awesome! Competent, professional and friendly - they stand behind their work and want the best for their clients. They are great at keeping us on our regular cleaning and maintenance schedule and send reminders via email and text. And if you have a need that can't wait, they do a great job of getting you in right away. Beautiful job on crowns and implant work as well. Happy to recommend. Originally posted on