SES-Child-Patient

11390 E Via Linda Ste 104 Scottsdale, AZ 85259 P: 480.867.1727 F: 480.867.1791
Child Name
Birthdate

MonthDayYear
Date
Gender

FemaleMaleNeutral
School
Grade
Preferred cell phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Email
example@example.com
How do you prefer to be contacted?

Phone CallTextEmail
How did you hear about us?

Friends/FamilyGoogleYelpInstagramFacebookOther
Who may we thank for referring your child to the office?
Person to contact in case of emergency
Phone #
Person responsible for account
Relation
Family members seen by us
List any sports or extracurricular activities
Parents' Marital Status

SingleMarriedDivorcedWidowedSignificant Other
Please check one

MotherStepmotherGuardianOther
If other, please specify:
Name

First NameLast Name
Birthdate

MonthDayYear
Date
SS#
Driver License #
Address(if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #
Phone Number

Area CodePhone Number
Employer
Occupation
Please check one:

FatherStep-FatherGuardianOther
Name
Birthdate

MonthDayYear
Date
SS #
Driver License #
Address

Address (if different than child's)

Street Address Line 2

CityState / Province

Postal / Zip Code
State
ZIP
Home #
Cell #
Employer
Occupation
Name of Subscriber
ID #
Insurance Co. Name
Group #
Information Release Authorization & Payment of Benefits Authorization
State your name
I hereby authorize the release of any information relating to any claim to third party payers. I hereby authorize and request my insurance company to pay diretly to the dentist or dental office insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants. I am aware that Smile Esthetics Scottsdale, LLC makes every effort to conform to HIPAA Privacy Regulations but that my health care information may be released in the course of coordination of treatment, obtaining payment and health care operations.
Parent or Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
Dental & Medical History (Minor)
Child Name
Age
Dental History
First Dental Visit?

YesNo
Previous X-Rays taken?

YesNo
Date of last X rays

MonthDayYear
Date
Previous dentist's name
Date of last visit

MonthDayYear
Date
Any unhappy dental experiences?

YesNo
Do you have well water or city water?
Any oral habits like pencil biting, thumbsucking, nail biting, pacifier?
Medical History
Child's Physician and Phone Number
Date of last exam

MonthDayYear
Date
For any YES answer below, please explain:
1. Is your child under the care of a physician (other than routine care) now?

YesNo
Please explain
2. Does your child take any medications or supplements?

YesNo
Please explain
3. Does your child have any allergies (i.e.:Penicillin, latex, etc.)?

YesNo
Please explain
4. Has your child ever been hospitalized?

YesNo
Please explain
5. Has your child ever had surgery?

YesNo
Please explain
6. Is there anything artificial in your child's body, such as pins, shunts, rods, etc.?

YesNo
Please explain
7. Are there any physical problems?

YesNo
Please explain
8. Are there learning difficulties?

YesNo
Please explain
9. Were there problems at or before birth?

YesNo
Please explain
10. Does your child have bleeding disorders?

YesNo
Please explain
Please check any of the following which may apply to your child now or in the past:

AnemiaDiabetesHeartMalignanciesAsthmaEpilepsyHepatitisRheumatic FeverCerebral PalsyFrequent InfectionsThyroidChronic SinusHeadachesKidneyTuberculosis TBConvulsionsHearingLiverHIV
Are there any current medical treatment including medications, pending surgery, recent injuries or any medical condition not listed above?
Consent to Treatment
The above information I have given is correct to the best of my knowledge and I understand it is my responsibility to inform this office of any changes in my child's medical status. As the parents or guardian of the above minor patient, I do request and authorize the performance of dental services for this patient, and the performance of any procedures or techniques the dentist may deem necessary during treatment. I authorize other individuals with whom I have placed the care of my child, such as other family members or caregivers, to sign consent for dental treatment for my child should they bring my child to any future appointments at Smile Esthetics Scottdale.
Parent or Legal Guardian Name:
Relationship to patient:
Parent or Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Information Release Authorization & Payment of Benefits Authorization

Dental & Medical History (Minor)

Dental History

Medical History

Consent to Treatment