Does this person have legal custody of this child?
Do you have other children seen by us?
Nearest relative not living with you
Do you or does any family member have a dental background or is employed in the dental field?
How did you hear about our office?
Additional Parent/ Legal Guardian Information
Please add information for any person who has legal custody of your child or else we will be unable to discuss patient information with that person
Reason for today’s visit (check all that apply)
What is your child’s attitude toward visiting the dentist?
Has your child complained about dental problems?
Has your child had any unhappy dental experiences?
Has your child had any injury to the mouth, head or teeth?
Does your child brush teeth daily?
Do YOU assist with tooth brushing?
Does your child have any of the following mouth habits:
Is child under the care of a physician now?
Is child receiving medication / drugs?
Has child ever been hospitalized?
Has child ever had surgery?
Is there any allergy to penicillin or other drugs?
Are there any other allergies (Latex, Metal, Food, Pollen, Animal, Dust, Dye, etc)?
Has your child ever had a blood transfusion?
Are there any emotional problems?
Has child had any reactions to anesthetics local and/or general?
Has child had any reactions to sedative agents?
Has this child had any treatment on any of the following?
I give my consent for my child to have a
I certify that I have read and understood the above questions. I will not hold Northeast Children’s Dentistry, Inc. or any member of its staff responsible for any errors or omissions I may have made in completion of this form. I authorize the release of information to all of my insurance companies. I understand that I am responsible for all financial responsibilities.