• Patient Information

  • Parents' Information

  • Is the child adopted?
  • Relationship
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Relationship
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Child Lives With:

  • Insurance Information

  • Do you have dental insurance?
  • Format: (000) 000-0000.
  • Is this child covered by Medicaid?
  • Does this child have secondary dental insurance?

  • Patient Health Information

  • Does your child have a health problem?*
  • Does your child take any medicine(s) regularly?*
  • Is you child allergic to penicillin?*
  • Has your child ever been hospitalized or had any surgical procedures?*

  • Has your child had any history of the following or currently being treated for:

  • ADD/ADHD*
  • Allergies*
  • Anemia*
  • Asthma*
  • Bleeding*
  • Cardiac Issues/Heart Murmur*
  • Cleft lip or palate*
  • Diabetes*
  • Dyslexia*
  • Disorder*
  • Epilepsy/Seizures*
  • Handicaps/Disabilities*
  • Hearing Impairment*
  • HIV/AIDS*
  • Emotional Issues*
  • Lung Disease*
  • Rheumatic/Scarlet Fever*
  • Speech Problems*
  • Tuberculosis*
  • Kidney/Liver Issues*

  • Has your child been tested for or diagnosed with any neurological disorders?

  • Autism*
  • Asperger’s Syndrome*
  • PDD*
  • Sensory Integration Disorder*
  • Is this your child’s first visit to the dentist?*
  • Has your child had any unfavorable dental experience?*
  • Does your child have a toothache now?*
  • Does your child suck his thumb or finger(s)?*
  • Does your child have a pacifier, nursing bottle or sipper cup habit?*
  • Have there been any injuries to teeth, falls, blows, chips, etc.?*

  • Consent for Treatment of a Minor

  • The undersigned hereby authorizes Alexandria Pediatric Dentistry to perform the examination and, after explanation, provide necessary dental services deemed appropriate for the care of the above-named child. This consent shall remain in full force and effect until cancelled by either party. I understand that I am responsible for notifying this office of any accidents, major illnesses, or changes in medical history of the above named child.

  • Should be Empty: