New Patient

New Patient
Child’s Name
Child's Name
First
Middle
Last
Nickname
Gender
Medicaid or Texas CHIP
Home Address
Home Address
City
State/Province
Zip/Postal
Does this person have legal custody of this child?
Is your child adopted?
Do you have other children seen by us?
Nearest relative not living with you
Nearest relative not living with you
First
Last
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?

Main Contact Parent/ Guardian Information

Name
Name
First
Last
xxx-xx-xxxx
Is this parent’s address the same as the child’s?
Address
Address
City
State/Province
Zip/Postal
Country

Additional Parent/ Legal Guardian Information

Name
Name
First
Last
xxx-xx-xxxx
Is this parent’s address the same as the child’s?
Address
Address
City
State/Province
Zip/Postal
Country
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)

Dental History

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?
Is floss used?
Do YOU assist with tooth brushing?
Does your child have any of the following mouth habits:
Is your child currently

Medical History

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?

Has this child ever been diagnosed as having any of the following conditions?

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.

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