Centerpoint Dental - Child New Patient Enrollment Form

We Welcome Your Family To Our Family!

Centerpoint Dental Child New Patient Enrollment Form
Child New Patient Information
Full Name*

First NameMiddle NameLast Name
Nickname
If applicable
E-mail
Social Security #*
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home #:*
Cell #*
Work #:*
What School Does Your Child Attend?*
What Grade Is Your Child In?*
Which Grade Is Your Child In?*

PreschoolKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thOther
Hobbies
How Did You Hear About Us?*
Other family members seen by us:
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Parent / Guardian Information
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Birthdate*

MonthDayYear
Date
Relationship to Patient*
Parent / Guardian Name

First NameLast Name
Parent / Guardian Birthdate*

MonthDayYear
Date
Relationship to Patient
Primary Insurance Information
Do you have insurance?

YesNo
Primary Insurance Carrier:*
Subscriber ID#:*
Group #:*
Insurance Phone Number*

Area CodePhone Number
Insurance Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name:*
Name of Insured:

First NameLast Name
Insured's Birthdate:*

MonthDayYear
Date
Insured's Social Security #*
Do you have secondary insurance?

YesNo
Secondary Insurance Information
Secondary Insurance Carrier:*
Secondary Subscriber ID#:*
Secondary Group #:*
Secondary Insurance Phone Number*

Area CodePhone Number
Secondary Insurance Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name:*
Name of Insured:*

First NameLast Name
Insured's Birthdate:*

MonthDayYear
Date
Insured's Social Security #*
Dental History
Is this your child's first dental appointment*

YesNo
If no, when was their last visit? *

MonthDayYear
Date
Is your child experiencing any pain/tenderness?*

YesNo
If Yes, Please Describe Their Pain or Discomfort*
Has your child ever had any serious/difficult problems associated with previous dental work?*

YesNo
Have there ever been any injuries to the face, mouth, teeth or chin?*

YesNo
Does your child Floss daily?*

YesNo
Does your child Brush daily?*

YesNo
Is your child's water fluoridated?*

YesNo
Is your child taking any fluoridated supplements?*

YesNo
Has your child experienced any of the following? (Check all that apply)*

Clenching / Grinding TeethLip Sucking / BitingMouth BreatherNail BitingNursing / Bottle HabitsSpeech ProblemsThumb / Finger SuckerTongue ThrustingNo
Medical History
Do You Have A Primary Care Physician?*

YesNo
Primary Care Physician:*
Primary Care Physician Phone Number:*

Area CodePhone Number
Date Of Last Visit To Your Primary Care Physician*

MonthDayYear
Date
Does your child take any medications or drugs?*

YesNo
If yes, please list it here*
Do You Have A Preferred Pharmacy?*

YesNo
Preferred Pharmacy Name:*
Preferred Pharmacy Location:*

Street Address

Street Address Line 2

CityState

Zip Code
Has your child ever been hospitalized?*

YesNo
If yes, please explain: *
Are the child's immunizations current?*

YesNo
Allergic to any of the following? (Select all that apply)*

NoneLatexPlasticsMetals / NickelSulfaMintPenicillinOther
What other allergies does your child have that we should we know about?*
Has your child had any of the following diseases or medical problems?*

NoADD / ADHDAIDS / HIV+Allergies / HivesAnemiaAnorexia / BulimiaArtificial Heart ValveAsthmaBladder ProblemsBlood TransfusionBruise EasilyCancer / LeukemiaCancer / LeukemiaCerebral PalsyChemotherapy / Radiation TreatmentChicken PoxCongenital Heart DefectDiabetesEpilepsy / Seizures / ConvulsionsHandicap DisabilitiesHearing ImpairmentHeart MurmurHemophilia / Abnormal BleedingHepatitisKidney ProblemsLiver ProblemsLupusLyme DiseaseMeasles / MumpsMononucleosisOral Cold SoresPsychiatric ProblemsRheumatic FeverScarlet FeverSinus ProblemsThyroid DiseaseTuberculosisUlcersOther
What other diseases or medical problems has your child had that we should we know about?
Consent
I affirm that the information that I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform any necessary dental services that my child may need during diagnosis and treatment with my informed consent.

Payment is due at time of service unless prior arrangements have been made. I understand that I am responsible for payment of services rendered and also responsible of any copay and deductibles that my insurance does not cover.
Patient/Guardian (Type Name)*

First NameLast Name
Patient / Guardian Signature: (use mouse or finger to draw your signature)*

Clear
Date*

MonthDayYear
Date

We Welcome Your Family To Our Family!

Child New Patient Information

Parent / Guardian Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

Consent

CONSENT FOR DENTAL TREATMENT OF MINOR