}

For Patient Registration

Patient Registration Form

Date
SS/HlC/Patient lD #
Birthdate
Name of Minor/Child
FirstLast
Sex
- M
- F
Age
Nickname
Hobbies
Phone
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Mailing Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
School Name
School Phone
Person financially responsible
Home Phone
Work Phone
Whom may we thank for referring you?
Father's/Guardian's Name
FirstLast
Address (if ditferent from patient's)
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Home Phone
Work Phone
E-mail
Employer
Soc. Sec. #
Birthdate
Do you have dental insurance coverage for minor/child?
- Yes
- No
Plan Name
FirstLast
Phone
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Group #
Policy #
ls your child eligible for treatment under Medical Assistance?
- Yes
- No
Mother's /Guardian's Name
FirstLast
Address (if different from patient's)
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Phone
Phone
Email
Employer
Soc. Sec. #
Birthdate
Do you have dental insurance coverage for minor/child?
- Yes
- No
Plan Name
FirstLast
Phone
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Group #
Policy #
Chitd's Medical Assistance l.D. #
Date
Has child complained about dental problems?
- Yes
- No
Does child brush teeth daily?
- Yes
- No
Does child use floss every day?
- Yes
- No
For what service?
ls fluoride taken in any form?
- Yes
- No
Any injuries to mouth, teeth, head?
- Yes
- No
Any unhappy dental experiences?
- Yes
- No
Any mouth habits - thumbsucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?
MinoriChild's Physician
City/State
Phone
Date of last physical examination
Results
ls MinoriChild under care of physician now?
- Yes
- No
Receiving any medication or drugs?
- Yes
- No
Ever been hospitalized?.
- Yes
- No
Ever had surgery?
- Yes
- No
ls there excessive bleeding when cut?
- Yes
- No
Medications
Allergies
Has minorlchild had any history of or difficulty with any of the following? lf yes, please check
- A.r.D.s.iH.l.v.
- Anemia
- Asthma
- Bladder Problems
- Cancer
- Cerebral Palsy
- Chicken Pox
- Convulsions
- Diabetes
- Drug/Alcohol Abuse
- Epilepsy
- Fainting
- Hearing Problems
- Heart Problems
- Hepalitis
- Kidney Disease
- Liver Disease
- Measles
- Mononucleosis
- Mumps
- Rheumatic Fever
- Sinus Problems
- Thyroid Disease
- Tuberculosis
- Other
ln ihe event of an emergency, whom should we contact?
Name
FirstLast
Relationship
Phone
Name
FirstLast
Relationship
Phone
Signature of Parent, Guardian or Personal Representatlve
Date
Please print name of Parent, Guardian or Personal Representative
Relationship to Patient
TO BE COMPLETED AT LATER VISIT
Has there been any change in patient's health since last dental appointment?
- Yes
- No
It yes, please describe
ls patient iaking any new medications?
- Yes
- No
lf yes, please list
Date
ParenVGuardian Signature
Date
Dentist Signature