Welcome!

Welcome!

Thank you for choosing Joyful Smiles Pediatric Dentistry for you child's dental care. We strive to make every child's visit exciting and educational. Our goal to teach good oral care that will enable your child to have a beautiful smile for a lifetime! Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
About Your Child
Name

First Name Last Name
Nickname:
Date of Birth

Month Day Year
Date
Age
Social Security Number *
School
Gender

Male Female
Grade
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Who is Accompanying The Child Today?

Guardianship
Name *

First Name Last Name
Relation *
Do you have legal custody of this child? *

No Yes
Parents
MOM'S INFORMATION
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
Home #:

Area Code Phone Number
Cell #:

Area Code Phone Number
Work #:

Area Code Phone Number
Employer
Social Security #:
DAD'S INFORMATION
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
Home #:

Area Code Phone Number
Cell #:

Area Code Phone Number
Work #:

Area Code Phone Number
Employer
Social Security #:
Person Responsible For Account
Name *

First Name Last Name
Relation *
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home #: *

Area Code Phone Number
Employer *
Work #: *

Area Code Phone Number
SS #: *
Primary Dental Insurance
Insurance Company's Name
Insurance Company's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company's Phone #:

Area Code Phone Number
Group # (Plan, Local or Policy #)
Policy Holder's Name
Relationship to Patient:
Policy Owner's Date of Birth

Month Day Year
Date
Policy Owner's Employer
Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Dental Insurance
Insurance Company's Name
Insurance Company's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company's Phone #:

Area Code Phone Number
Group # (Plan, Local or Policy #)
Policy Holder's Name
Relationship to Patient:
Policy Owner's Date of Birth

Month Day Year
Date
Policy Owner's Employer
Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child's Dental History
Has the child ever had a serious/difficult problem associated with previous dental work? *

Yes No
Is the chid's water fluoridated? *

Yes No
Is the child taking fluoridated supplements? *

Yes No
Has the child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)? *

Yes No
Does the child brush his/her teeth daily? *

Yes No
Floss his/her teeth daily? *

Yes No
Does/did the child have any of the following habits? *

Lip Sucking/Bite Nail Biting Nursing Bottle Habits Thumb/Finger Sucking
Medical History

Has the child ever had any of the following medical problems?
Abnormal Bleeding *

Yes No
ADD/ADHD *

Yes No
Allergies to any drugs *

Yes No
Any Hospital Stays *

Yes No
Any Operations *

Yes No
Artificial Bones/Joints/Valves *

Yes No
Aspergers Syndrome *

Yes No
Asthma *

Yes No
Autism *

Yes No
Cancer *

Yes No
Congenital Heart Defect *

Yes No
Convulsions/Epilepsy *

Yes No
Diabetes *

Yes No
Handicaps/Disabilities *

Yes No
Hearing Impairment *

Yes No
Heart Murmur *

Yes No
Hemophilia *

Yes No
Hepatitis *

Yes No
HIV+/AIDS *

Yes No
Kidney/Liver Problems *

Yes No
Rheumatic/Scarlet Fever *

Yes No
Sickle Cell Disease/Traits *

Yes No
Tuberculosis (TB) *

Yes No
Child's Physician Name *
Date of Child's Last Physician Visit *

Month Day Year
Date
Is the child currently under the care of a physcian *

Yes No
Please describe the child's current physical health *

Good Fair Poor
Has your child ever taken Fosamax, or any other bisphosphonate? *

Yes No
Has your child ever taken Phen-Fen? *

Yes No
Please list all drugs that the child is currently taking: *
Please list all drugs/materials that the child is allergic to: *
Does your child have a latex allergy? *

Yes No
Does your child have a metal or nickel allergy? *

Yes No
Does your child have a plastic allergy? *

Yes No
Please discuss any serious medical problems that the child has had:
Emergency Contact

Please list a neighbor or Relative not living with you
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
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 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 the neccessary dental services my child needs. The Parent or Guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved. *

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Welcome!

About Your Child

Who is Accompanying The Child Today?

Parents

Person Responsible For Account

Primary Dental Insurance

Secondary Dental Insurance

Child's Dental History

Medical History

Emergency Contact