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
Date
Child's Name*

First NameMiddle NameLast Name
Nickname
Gender*

MaleFemale
Child’s Birthdate: *

DayMonthYear
Child's Age:*
School: *
Grade: *
Child’s Home #*
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?*

YesNo
Whom may we thank for referring you?*
Other family members seen by us?
Previous / Present Dentist
Last Visit Date

DayMonthYear
Parent’s Marital Status

SingleWidowedMarriedDivorcedSeparated
Mother’s Information
Circle One*

Step MotherGuardian
Name*
Work #:
Please enter a valid phone number.
Ext
HM #*
Please enter a valid phone number.
Employer
SS #
Email: *
example@example.com
Father’s Information
Circle One*

Step MotherGuardian
Name
Work #:
Please enter a valid phone number.
Ext
HM #
Please enter a valid phone number.
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.
Ext
HM#
Please enter a valid phone number.
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.
Group # (Plan, Local or Policy #)
Insured’s Name
Relation
Insured’s Birthday

DayMonthYear
Date
Insured’s SS#
Insured’s Employer
Orthodontic Coverage?

YesNo
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.
Group # (Plan, Local or Policy #)
Insured’s Name
Relation
Insured’s Birthday

DayMonthYear
Insured’s SS#
Insured’s Employer
Orthodontic Coverage?

YesNo
Why Did You Bring the Child to the Dentist Today?
Has the child ever had a serious / difficult problem associated withprevious dental work?

YesNo
Is the child taking fluoridated supplements?

YesNo
Has the child ever had any pain/tenderness in their jaw joint (TMJ/TMD)

YesNo
Does the child brush their teeth daily?

YesNo
Floss their teeth daily?

YesNo
Child’s Physician
Phone#:
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
Is the child currently under the care of a physician?

YesNo
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?

Heart MurmurCancerDiabetesRheumatic FeverHIV+ / AIDSHemophiliaAsthmaHepatitisTuberculosis (TB)Congenital heart DefectConvulsions / EpilepsyAbnormal BleedingHearing ImpairmentAny OperationsAny Stays in a HospitalKidney / Liver ProblemsHandicaps / DisabilitiesAllergies to any drugsSeasonal Allergies
Please list any serious medical condition(s) that the child has had:
Does the Child Have Any of the Following Habits?

Difficulty Breathing Through NoseThumb / Finger SuckingLip Sucking / BitingNail BitingNursing Bottle 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

Clear
Date

DayMonthYear
Date
I verbally reviewed the medical / dental information above

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

MonthDayYear
Date
Doctor’s Comments:
Medical History Update
Date

DayMonthYear
Date
Signature

Clear
Date

DayMonthYear
Date
Signature

Clear
Billing Address:
I hereby authorize payment directly to the below name dentist of the group insurance benefits otherwise payable to me.
SIGNED (Insured Person)

Clear
PAUDEN_110 (03/15)
Name
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

PAUDEN_110 (03/15)