New Patient Form (English)

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

MonthDayYear
Date
Age
Number of Children in Family
School
Father's Name
Father Information
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
Marital Status
Mother's Name
Mother Information
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
Marital Status
With whom does this child reside?
Preferred Email Address
example@example.com
Preferred Contact Method for Appointments
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?
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?
Is your child sensitive or have allergies to any medications, latex, or foods?
If Yes, Please list
Is your child taking any medications?
If Yes, Please list
Has your child ever had any surgeries?
If Yes, Please list
Does your child have any history of the following conditions (check all that apply):
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?
Is your child taking fluoride pills or drops?
Is your child in any contact sports?
Has your child ever had an orthodontic evaluation or treatment (braces)?
Name of Orthodontist
Is there any other information which will assist us in providing the best possible care for your child?
Please state here
How did you hear about our office?
Do you have Dental Insurance?
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?
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
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