Demographic and Medical History

New Patient Information

All required fields must be filled. Use N/A if not applicable
Child's Name:*

First NameMiddle NameLast Name
Date of Birth* Age* Gender*

School Grade
Parent 1 (present at appointment)*

First NameLast Name
Street Address*      City*   State*Zip*

Cell Phone*   Home Phone*   Email*

SS#*    Date of birth*
Insured Parent*

First NameLast Name
SS#* Date of birth* Phone Number*

Employer* Insurance (if any)* Group Number*
Parent 2

First NameLast Name
Relationship to Child   SS# Date of birth   Phone Number

Street Address      City   State   Zip

Employer Insurance (if any) Group Number
How did you hear about Sparkles? *
Date of Last Visit to Dentist?

MonthDayYear
Date
For what treatment?*
Please list any medical conditions: (Asthma, Allergies, Heart disease/disorders, Hepatitis, Neuromuscular disorders, Autoimmune Disorders, Autism Spectrum Disorders, ADD/ADHD, Hematological Disorders, others)*
Please list all current medications: (Over the counter, prescription, vitamins, supplements):*
Please list all allergies: (Medication allergies, food allergies, other)*
Is your child up to date on vaccinations against childhood diseases? (DTap, MMR, HIB, Hepatitis B, Varicella, Pneumococcal, Meningococcal, Hepatitis A)*

YesNoOther
If other, please list reason:*
Are there any vaccinations that your child does NOT receive?*

Health History
Physician's Name*

Physician's address*      City*   State*   Zip*

Date of last physical examination*   Results*

Vaccinations on a delayed schedule?*

Hospitalizations or had surgery?*

Special needs or disabilities?*
Please describe any current medical treatment including drugs, pending surgery, recent injuries, or any other information we should be aware of that we have not discussed (write "none" if not applicable):*
Dental History
Check any that apply:

Does your child brush teeth twice daily?Has child complained about dental problems?Has child had any unhappy dental experiences?Does child have any oral habits—thumb sucking, nail biting, mouth breathing, nursing, bottle, pacifier, etc.?Any unusual speech patterns?Do you assist child with brushing their teeth?Does child use dental floss?Does child take fluoride in any form?Has child sustained any injuries to mouth, teeth, or head?
Signature

To the best of my knowledge, the foregoing questions have been accurately answered. I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners. I give the doctor permission to use any photographs taken for educational and commercial purposes. I also give permission to obtain copies of records and x-rays from my previous dentist(s).
Signature of person completing this form:*

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New Patient Information