6. Insurance Company
Zip
City
Address
Insurance Co.
Employer
ID #
Group #
DOB
Please Choose ALL Referral Sources
Date Male Female
Patient’s Name
Age_______ Birthdate_____________________________
Address ________________________________________
Phone_________________________________________
Mother’s Name
DOB
Home #_______________ Cell #____________________
E-Mail
Father’s Name
________________________________
Home #_______________ Cell #___________________
E-Mail _________________________________________
Primary Insurance
Secondary Insurance
___________________
___________________
___________________
Patient Information Dental Insurance
Has your child ever seen another dentist?
Yes No
Date of the last visit __________________________________
Name of dentist _____________________________________
Were Radiographs taken? _____________________________
11. Pediatrician Name
Preferred method of contact
________________________________
Text E-mail
Cell Phone
Home Phone
SSN
DOB SSN
Is the patient living with both parents:
Y
N
Policy Holder Name
___________________
Policy Holder Name
Has your child ever injured their head, mouth and/or teeth?
Yes
Does/did your child take a bottle to bed at night?
Yes No
Is your child having dental problems now? Yes No
Does Your Child
Have sleep, snoring, or breathing issues?
Awaken at night or come to bed with you?
Have allergies or ear infections?
Is your child a mouth breather?
Does/ Did your child have a finger or pacifier habit?
Was your child breast fed?
Are you concerned about your child’s speech?
_______________ ___________________
NEW PATIENT REGISTRATION
SMILES...That Last a Lifetime
No
Explain ___________________________
Explain
___________________________________________
____________________________
____________________________
____________________________
____________________________
__________________
____________________________
____________________________
Dental History
Sleep & Breathing History
1. Website
2. Google Search
3. Billboard
Parents were Patients
Community Event ___________
Facebook
4. KidZdent Sign / Drive By
9. Patient Name
10. Dentist Name
12. Name of School
_____________________________
_____________________________
_____________________________
Social Security # _________________ DOB ______________
Group #
_____________________________
ID #
_____________________________
Employer______________________________
_
___________
_
I certify that I (or my dependant) have insurance coverage and
assign directly to KidZdent all insurance benefits. I understand
that I am financially responsible for all charges whether or not
paid by insurance. I authorize the use of this signature on all
insurance submissions.
Signature _____________________________ Date _______________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Insurance Company
Address
Social Security #
State
Patient’s Physician _______________________________
Physician’s Phone Number _________________________
Are all immunizations up to date _____________________
Date and reason for last examination by physician
_______________________________________________
Has your child ever had a general anesthetic? __________
If yes, please explain ______________________________
Is your child allergic to any Medications? Yes No
If yes, list all medications ____________________________
Are there any other allergies? Yes No
If yes, please list ___________________________________
_________________________________________________
Is your child taking medications now? Yes No
If yes, please list ___________________________________
Medical History
Medical Conditions
APPOINTMENT POLICY: PLEASE NOTIFY THIS OFFICE 24 HOURS PRIOR TO AN APPOINTMENT IF YOU
MUST CANCEL IT. THIS OFFICE RESERVES THE RIGHT TO CHARGE A CANCELLATION FEE.
KidZdent follows Federal and State law by complying with HIPPA standards. Our Notice of Privacy Practices took
effect on April 15, 2003 and is available to you at request.
I certify that I have read and understood the above. I understand that the information that I have given is correct to
the best of my knowledge. I will not hold KidZdent or any member of the staff responsible for any errors or omis-
sions I may have made in the completion of this form. I also authorize the Doctor’s and staff of KidZdent to perform
the necessary dental services that they have explained me.
Signature of Parent/Guardian _______________________________________________________ Date ______________
Social & Behavioral History
Please check all conditions that apply:
Y N
Latex Allergy
ASD/ Autism
Extreme Nervousness or Apprehension
Developmentally Delayed
Cerebral Palsy
Hyperactivity/ ADHD
Learning Disability
Psychiatric Care/ Emotional Ailments
Asthma or Other Respiratory Ailments
Liver Ailments, Jaundice or Hepatitis
Y N
Heart Ailments
Rheumatic Fever
Epilepsy or Seizures
Heart Murmur
Sinus Ailments
Tonsillitis
Tuberculosis
Kidney Ailments
Diabetes
Aids/HIV+
Y N
Thyroid Disorders
Ulcer or Colitis
Malignancies or Leukemia
Chicken Pox
Mononucleosis
Hearing Ailments
Eye disorders
Physical Handicaps
Excessive Bleeding
Anemia or Blood Ailments
Other Medical Conditions __________________________________________________________________________________________
Interests _________________________________________ Favorite Toys ______________________________________
Sports Played _____________________________________ Pets _____________________________________________
Special Experience_________________________________ Favorite Video Game________________________________
Is there anything else that you think we should know about your child? ____________________________________________
