New Patient Paperwork

New Patient Paperwork

Child/Minor (1-17) Form
Thank you so much for filling out your child's new patient paperwork prior to their appointment. This gives the doctors a chance to review everything ahead of time and expedite your first visit with us. We look forward to meeting you, and please don't hesitate to give the office a call if you need any assistance (818) 532-2977.

- The Garfinkle Family Dental Team
Basic Information
Child's Full Name

First NameLast Name
Preferred Name
[If different than their legal name]
Date of Birth

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name

First NameLast Name
Mother's Phone Number

Area CodePhone Number
Father's Name

First NameLast Name
Father's Phone Number

Area CodePhone Number
Please Contact

MotherFatherEither/Both
Email Address
[For appointment reminders only]
Whom/What can we thank for referring you?*
In Case of Emergency Contact
Full Name and Relationship
Phone Number

Area CodePhone Number
Dental Insurance Information
Will we be assisting you with filing dental insurance?

YesNo (please skip to dental health history)
Insurance Company Name
[including state if applicable]
Subscriber's Full Name
Subscriber's ID Number (#)
Subscriber's Date of Birth

MonthDayYear
Dental Health History
By checking the boxes below, you indicate a "YES" response and leaving it blank indicates a "NO" response.
Had problems w/previous dental treatment?Does your child gag easily?Does food catch between their teeth?Do they have difficulty chewing?Do they chew on only one side of the mouth?Do they avoid brushing any particular area?Do their gums bleed easily?Do their gums bleed when they floss?Do their gums feel swollen or tender?Have you ever noticed slow-healing sores?Does their jaw make noise?Are your child’s teeth sensitive?
Medical Health History
Please note you will be asked each visit if there has been any changes or additions to this medical history, and it is imperative you let us know if anything changes so we can continue to provide you the most comprehensive dental care.
By checking the boxes below, you indicate a "YES" response and leaving it blank indicates a "NO" response.
Does your child have, or have ever had any of the following?

AnemiaArthritisArtificial JointsAsthmaBlood DiseaseBone/Joint ProblemsCancerDiabetesDizzinessEasily BruiseEpilepsyExcessive BleedingFaintingGlaucomaHeadaches (Frequent/Severe)Head InjuryHeart DiseaseHeart MurmurHepatitis (A, B or C)High Blood PressureHistory of Tobacco UseHistory of Drug/Alcohol AbuseHIV (Human Immunodeficiency Virus)HPV (Human Papillomavirus)JaundiceKidney DiseaseLiver DiseaseMental Disorder(s)Nervous DisordersPacemakerRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSeizuresSinus ProblemsStomach ProblemsStrokeThyroid ProblemsTuberculosisTumorsUlcersVenereal Disease
WOMEN ONLY

Are you pregnant, trying to conceive or nursing?Are you taking any form of contraceptive?
Is your child required by a physician to medicate with antibiotics prior to dental appointments?

YesNo
Please list any allergies:

NonePenicillin, Amoxicillin or other antibioticsAspirin, Acetaminophen or IbuprofenCodeine, Demerol or other narcoticsLatex or other rubber(s)Local Anesthetics (“Novocaine”)Reaction to MetalsOther
Please list any/all current medications (including herbal):
Primary Care Physician (if applicable):
Full Name
Phone Number

Area CodePhone Number
By selecting "Submit Paperwork" below, your information will securely and safely forwarded to our office. Upon your arrival, you will be asked to sign a copy of our Office Policies and our Acknowledgement of HIPAA Privacy Practices. Again, we look forward to meeting you and your child!
Should be Empty:

New Patient Paperwork

Basic Information

Dental Insurance Information

Dental Health History

Medical Health History