New Patient Form (English)

New Patient Welcome Sheet
Child's Full Name*
Preferred Name*
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
Age*
Number of Children in Family*
School
Father's Name
Father Information

GuardianStepfather
Birthdate

MonthDayYear
Date
Social Security Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Father's Occupation
Employer
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Best Contact Number

HomeCell PhoneWork Phone
Marital Status

MarriedSingleDivorcedSeparatedWidowed
Mother's Name
Mother Information

GuardianStepmother
Birthdate

MonthDayYear
Date
Social Security Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Mother's Occupation
Employer
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Best Contact Number

HomeCell PhoneWork Phone
Marital Status

MarriedSingleDivorcedSeparatedWidowed
With whom does this child reside?*
Preferred Email Address*
example@example.com
Preferred Contact Method for Appointments*

Phone CallText
Preferred Email or Mobile Number
In case of emergency, other than those listed above, whom may we contact?
Name*
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Relationship*
Medical History

Please answer all questions, so that we may assess your child's oral health as accurately as possible. All information will be kept strictly confidential. Thank you!
Is your child presently under the care of a physician?*

YesNo
If so, for what condition?*
Child’s Physician/Primary Care Doctor*
Office Name*
Phone

Area CodePhone Number
Date of Last Physical Exam
Findings
Former Dentist
Office Name
Phone

Area CodePhone Number
Is your child in good health?*

YesNo
Is your child sensitive or have allergies to any medications, latex, or foods?*

YesNo
If Yes, Please list
Is your child taking any medications?*

YesNo
If Yes, Please list
Has your child ever had any surgeries?*

YesNo
If Yes, Please list
Does your child have any history of the following conditions (check all that apply):

AsthmaBleeding ProblemBlood TransfusionHeart ProblemHeart MurmurDiabetesThyroid ProblemSeizure or EpilepsyMotor or Muscle DisorderFainting or DizzinessLiver DiseaseKidney DiseaseTuberculosis (TB)HIV/AIDSAutisticHearing DifficultySpeech DelayDevelopment DelayPsychiatric ProblemADD / ADHD
Does your child have any other Problems, Conditions or Special Needs?
Has your child had any history of oral habits like thumb/finger sucking or lip biting?*

YesNo
Is your child taking fluoride pills or drops?*

YesNo
Is your child in any contact sports?*

YesNo
Has your child ever had an orthodontic evaluation or treatment (braces)?*

YesNo
Name of Orthodontist
Is there any other information which will assist us in providing the best possible care for your child?*

YesNo
Please state here
How did you hear about our office?*
Do you have Dental Insurance?*

YesNo
Primary Dental Insurance
Employee
Relationship to Parent
Employer
Insurance Co.
ID Number
Insured Birthdate

MonthDayYear
Date
Employee's SS Number
Do you have Secondary Dental Insurance?*

YesNo
Secondary Dental Insurance
Employee
Relationship to Parent
Employer
Insurance Co.
ID Number
Insured Birthdate

MonthDayYear
Date
Employee's SS Number
Person financially responsible for child’s account:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize Drs. Nielson and Smith and/or dental staff to perform the necessary dental services my child may need. This may include exams, radiographs, cleanings, topical fluoride treatment, restorative dentistry, oral surgery or limited orthodontics. In order to perform such treatment, our team may recommend the use of local anesthesia (numbing) and/or nitrous oxide (laughing gas), conscious sedation or general anesthesia.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Welcome Sheet

In case of emergency, other than those listed above, whom may we contact?

Medical History

Primary Dental Insurance

Secondary Dental Insurance