Required fields (*) CHILD’S NAME: First Name* Last Name* Birthdate * Age* School* Home Address* City* State* Zip Code* Gender MaleFemale Child lives with: (select one)*FatherMotherBothOther Marital status of parents: (select one)* MarriedSingleDivorcedSeparatedWidowed FATHER: First Name* Last Name* Social Security Number* Cell Phone* Home Phone Birthdate* Employer* Work Phone* E-mail Address* Home Address (if different than child’s) MOTHER: First Name* Last Name* Social Security Number* Cell Phone* Home Phone Birthdate* Employer Work Phone E-mail Address* Home Address (if different than child’s) PAYMENT OPTIONS: Method of payment (please select one)* Cash, Check or Credit CardInsurance and co-payMedicaid and co-pay PRIMARY DENTAL INSURANCE: Subscriber Name Phone Subscriber ID/SSN Address Insured Person's Name SECONDARY DENTAL INSURANCE: Name Phone Policy Address Insured Person's Name HEALTH (medical) INSURANCE INFO: Name Address Phone Insured Persons Name REFERRAL INFORMATION: Dental OfficeInternetAnother PatientFriendSchoolWorkOther Which dentist recommended you to us? DENTAL HISTORY Reason for your child's visit? Is there a specific problem? Has your child been to the dentist before? Date? How was your child's experience? Is your child's currently taking floride? How often? Has your child had X-Rays before? When? Is your child currently on the bottle? Pacifier Sippy cup? Nursing Thumb sucking? Grinding? Do you currently help your child brush and floss? How ofted does He or She brush? Does your child have TMJ/TMD? MEDICAL HISTORY Name of Physician Is your child's currently taking medication? If yes, what? Has your child ever had a traumatic medical/dental injury? If yes, for what? Date? Has your child ever been hospitalized? If yes, for what? Date? DOES YOUR CHILD HAVE, OR PREVIOUSLY HAD, ANY OF THE FOLLOWING Please check all that apply Autistm ADHD Aids Allergies Anemia Artificial Joints Athsma Blood Disease/Disorder Blood Transfusion if yes, date: Behavioral/Learning Disorder Breathing/Lung Problems if yes, explain: Cancer/Tumor Congenital Birth Defects Multiple Ear Infections Tubes In Ears Endocrine System Fainting Hearing/Vision Heart Murmur Heart Condition Head Injury Frequent/Recurrent Headaches Kidney Disease Liver Disease Mental Disorder Mental/Physical Developmental Delay Pregnancy if yes, due date: Gi System Radiation Treatement Respitory Treatement Respitory Problem Rheumatic Fever Seizures Tuberculosis Down Syndrome Vomiting/Diarrhea Allergies/Adverse Reaction to Medicationif yes, what type: Frequent Infections if yes, what type: Any other medical conditions not listed: If you’ve checked any box above, please describe your situation in detail. I have completed this form with the most accurate information I have, and understand that I am responsible for what I have submitted Stansbury Kids Pediatric Dentistry is committed to keeping your information private. All our forms are secured, and HIPAA compliant. Δ
