PDF: Child Patient Form for Pauly Dental

We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational.
Tell Us About Your Child
Todays Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Child's Name

First NameMiddle NameLast Name
Nickname
Gender
Child’s Birthdate:

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Child's Age:
School:
Grade:
Child’s Home #
Format: (000) 000-0000.
SS#
Child Home Address

APT/CONDO#

Street Address Line 2

CityState

Zip Code
Who is Accompanying the Child Today?
Name
Relation
Do you have legal custody of this child?
Whom may we thank for referring you?
Other family members seen by us?
Previous / Present Dentist
Last Visit Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Parent’s Marital Status
Mother’s Information
Name
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
Ext
HM #
Please enter a valid phone number.Format: (000) 000-0000.
Employer
SS #
Email:
example@example.com
Father’s Information
Name
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
Ext
HM #
Please enter a valid phone number.Format: (000) 000-0000.
Employer
SS #
Email:
example@example.com
Person Responsible for Account
Name
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
Ext
HM#
Please enter a valid phone number.Format: (000) 000-0000.
Employer
SS #
DL #
Who is Responsible For Making Appointments
Name
Work#
Ext
HM#
Primary Dental Insurance
Insurance Company Name
Insurance Co. Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Co. Phone#
Please enter a valid phone number.Format: (000) 000-0000.
Group # (Plan, Local or Policy #)
Insured’s Name
Relation
Insured’s Birthday

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Insured’s SS#
Insured’s Employer
Orthodontic Coverage?
Secondary Dental Insurance
Insurance Company Name
Insurance Co. Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Co. Phone#
Please enter a valid phone number.Format: (000) 000-0000.
Group # (Plan, Local or Policy #)
Insured’s Name
Relation
Insured’s Birthday

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Insured’s SS#
Insured’s Employer
Orthodontic Coverage?
Why Did You Bring the Child to the Dentist Today?
Has the child ever had a serious / difficult problem associated withprevious dental work?
Is the child taking fluoridated supplements?
Has the child ever had any pain/tenderness in their jaw joint (TMJ/TMD)
Does the child brush their teeth daily?
Floss their teeth daily?
Child’s Physician
Phone#:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the child currently under the care of a physician?
Please describe the child’s current physical health:
Please list all drugs that the child is allergic to:
Has the Child Ever Had Any of the Following Medical Problems?
Please list any serious medical condition(s) that the child has had:
Does the Child Have Any of the Following Habits?
Our Office is committed to meeting or exceeding the standards of
infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services my child may need.
Signature of Patient or Guardian
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
I verbally reviewed the medical / dental information above

with the parent / guardian & patient named herein.
Initials
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctor’s Comments:
Medical History Update
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Billing Address:
I hereby authorize payment directly to the below name dentist of the group insurance benefits otherwise payable to me.
SIGNED (Insured Person)
I(Name)* Have received a copy of this office's Notice of Privacy Practices.
Please Print Name*
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Tell Us About Your Child

Who is Accompanying the Child Today?

Mother’s Information

Father’s Information

Person Responsible for Account

Who is Responsible For Making Appointments

Primary Dental Insurance

Secondary Dental Insurance