Madison New Patient Form Pediatric Dentistry

Preferred Office Selection for First Appointment

Who can we thank for referring you to our office?

Patients Full Name

First NameLast Name

Patients Preferred Name:

Patients Date of Birth

MonthDayYear

Patients Social Security #:

Patients Gender

Patients Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient E-mail

Phone Number

Area CodePhone Number

Patient Lives With:

First NameLast Name

Primary Guardian:

First NameLast Name

Primary Guardian Relationship to Patient:

Primary Guardian Date of Birth

MonthDayYear

Primary Guardian SS #

Primary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Primary Guardian E-mail

Primary Guardian Mobile Phone

Area CodePhone Number

Primary Guardian Home Phone

Area CodePhone Number

Primary Guardian Occupation

Primary Guardian Employer

Primary Guardian Work Phone

Area CodePhone Number

Primary Guardian Marital Status

Primary Guardian Spouse

First NameLast Name

Secondary Guardian:

First NameLast Name

Secondary Guardian Relationship to Patient:

Secondary Guardian Date of Birth

MonthDayYear

Secondary Guardian SS #

Secondary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Secondary Guardian E-mail

Secondary Guardian Mobile Phone

Area CodePhone Number

Secondary Guardian Home Phone

Area CodePhone Number

Secondary Guardian Employer

Secondary Guardian Occupation

Secondary Guardian Work Phone

Area CodePhone Number

Secondary Guardian Marital Status

Secondary Guardian Spouse

First NameLast Name

May we leave a message about upcoming appointments with

Emergency Contact

First NameLast Name

Emergency Contacts Relationship to Patient

Emergency Contacts Phone

Area CodePhone Number

Emergency Contacts Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please check any of the conditions that apply to the patient

Please describe the condition(s) you have indicated including the history, current treatment or therapy, and any information that might be relevant

Is the patient currently taking any medications?

Please list any current or relevant medications being taken

Does the patient have any allergic or adverse reactions to medications?

Please describe any adverse or allergic reactions to medications

Known Common Allergies

Please List any other allergies known for this patient

Is the patient currently under a Physicians Care?

Physicians Name

First NameLast Name

Physicians Phone Contact

Area CodePhone Number

Physicians Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please explain what conditions and any treatments that the patient is under the Physicians care for.

When was the patients last visit or checkup with the physician

MonthDayYear

Please check any of the following conditions that apply to the patient

How would you predict your childs reaction to visiting our staff and office?

Describe your child's current oral health

What are your primary concerns about your child's oral health if any?

Is your child covered by insurance?

Primary Insurance Company Name

Primary Insurance Company Phone

Area CodePhone Number

Employer Providing Coverage

Employee Name Provided Coverage

Employee SS # Provided Coverage

Primary Insurance Group #

Primary Insurance Policy #

Is your child covered by a Secondary insurance provider?

Secondary Insurance Company Name

Secondary Insurance Company Phone

Area CodePhone Number

Secondary Employer Providing Coverage

Secondary Employee Name Provided Coverage

Secondary Employee SS # Provided Coverage

Secondary Insurance Group #

Secondary Insurance Policy #

Signature I agree, sign and initial the Medical/ Dental Release, Filing Insurance Claims Release, and the Privacy Policy Release Forms

Note: Click here to read our Payment for Services Policy

Note: Click here to read our Practice Guidelines

Note: Click here to read our Notice of Privacy Practices

I have read The following and agree to the terms of usage

Enter the message as it's shown

New Patient Form Pediatric Dentistry Madison Office