Child's Registration History

Welcome to our practice! We strive to make each of your child's visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their lifetime.
Today's Date

Month Day Year
Date
Your Child
Child's Name

First Name Last Name
Nickname
Sex

Male Female
Birthday

Month Day Year
Date
Age
Social Security Number
School
Grade
Child's Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child's Phone

Area Code Phone Number
Mother
Relationship with child

Mother Stepmother Guardian
Name

First Name Last Name
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Social Security Number
Employer
Occupation
Drivers License Number
Father
Relationship with child

Father Stepfather Guardian
Name

First Name Last Name
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Social Security Number
Employer
Occupation
Drivers License Number
Who is responsible for making appointments?
Name

First Name Last Name
Relationship
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Best Time To Call (Time and Days)
Parents' Marital Status

Single Married Divorced Separated Widowed
Regardless of divorce judgements we consider the responsible party for the payment of any co-pay or balance due to be the parent or guardian that brings the child to appointments.
Dental Insurance
Insured's Name

First Name Last Name
Employer
Relationship to Patient
Social Security Number
Date of Birth

Month Day Year
Date
Group Number
Health History: Your Child's overall health as well as any medications which your child takes could have an important interrelationship with dental care your child receives. Please answer each of the following questions completely.
Date of Last Visit to Dentist

Month Day Year
Date
For What Service?
Has Your Child Complained About Any Dental Problems?
Any Injuries to Mouth-Teeth-Head?
Any Mouth Habits: Thumb Sucking, Nail Biting, Mouth Breathing, Bottle Habits, Pacifier, ect.
Any Unusual Habits?
Missing Teeth?
Orthodontic Appliances?
Does Your Child Brush Teeth Daily?
Do You Assist Your Child Brushing?
How Often?
Does Your Child Use Dental Floss/How Often?
Are Disclosing Tablets Used?
Is Fluoride Taken In Tablet Or Supplement?
Is Child Under Care Of Physician Now?
Is Child Receiving Any Medication Or Drugs, If So What?
Is There Any Excessive Bleeding When Cut?
Has Child Ever Been Hospitalized?
Has Child Ever Had Surgery?
Is There Any Allergy To Penicillin Or Other Drugs?
Any Allergies: Food, Pollen, Animals, Dust, Other?
Does Child Have Good Physical Coordination?
Any Emotional Problems?
Health History
Has Child any history of or difficulty with any of the following?

Allergies Anemia Asthma Bladder Cancer Cerebral Palsy Chicken Pox Chronic Sinus Convulsions Congenital Heart Defect Heart Murmur Diabetes Epilepsy Fainting Hearing Heart Hemophilia Hepatitis HIV/AIDS Kidney Liver Malignancies Mastoid Measles Mononucleosis Mumps Rheumatic Fever Thyroid Tuberculosis
Authorization and Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care to third party payors and/or health practitioners. I authorize benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.
Signature of patient or parent/guardian if minor

Clear
Month Day Year
Date
History reviewed by:

Clear
Month Day Year
Date
Should be Empty:

Your Child

Mother

Father

Health History