Patient Registration form and medical history little smiles

PATIENT REGISTRATION INFORMATION

Child's First Name

Middle Initial

Last Name

Preferred Name

Gender

Male Female

Date of Birth

Age

Address

City

State

Zipcode

Home Phone

RESPONSIBLE PARTY

Responsible Person First Name

Middle Initial

Responsible Person Last Name

Date of Birth

Social Security #

Driver's License #

Home Phone

Address

City

State

Zipcode

Cell Phone

Business Phone

Ext:

Email

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder

Primary Insurance Company

Relationship to Insured

Self Spouse Child Other

Primary Policy Holder

Primary Policy Holder

Social Security #

Date of Birth

Primary Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Group #

Group ID

Who can we thank for referring you to our office?

Signage New Resident Gift Yelp

Google Social Media Insurance

Print Ad Mailer/Postcard Community Event

Print Ad

Mailer/Postcard

Community Event

Current Patient Referring Doctor Website: Little Smiles

Current Patient

Referring Doctor

Website: Costa Family & Cosmetic Dentistry

Medical History

Child's Physician

Date of Last Physical Exam

Address

Phone

Parents/Guardians please respond and check Yes or No

Is your child currently being treated by a physician for a specific illness or disorder?

Yes No

If so, for what reason?

Is your child taking any medications at this time? (please list all drugs below)

Yes No

Medication

Dosage/Frequency

Reason

Medication

Dosage/Frequency

Reason

Medication

Dosage/Frequency

Reason

Has your child experienced any allergies or unusual reactions? (please list any allergies below)

Yes No

Medications

Foods

Other

Were there any complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions?

Yes No

Please describe

Has your child ever been hospitalized? When and for what reason?

Yes No

Please describe

Has your child had any operations? When and for what reason?

Yes No

Please describe

Please check if your child has a history of the following conditions

Accidents or Severe Infections

Yes No

ADD/ADHD

Yes No

Anemia or Blood Disorders

Yes No

Asthma or Lung Problems

Yes No

Autism

Yes No

Cerebral Palsy

Yes No

Congenital Heart Defect/Murmur

Yes No

Diabetes

Yes No

Gastrointestinal Disorders

Yes No

Headaches

Yes No

Hemophilia/Abnormal Bleeding

Yes No

Intellectual Disability

Yes No

Kidney or Bladder Problems

Yes No

Leukemia

Yes No

Liver Problems or Hepatitis

Yes No

Radiation/Chemotherapy

Yes No

Seizures/Epilepsy

Yes No

Speech or Hearing Disorder

Yes No

Tumor or Cancer

Yes No

Vision Problem

Yes No

Does your child’s physician recommend antibiotic premedication for your child prior to dental procedures?

Yes No

Is there any other significant medical history pertaining to your child that the dentist should be aware of?

Yes No

Provide details here:

Dental History

What is the reason for your child's visit today?

Dental Experience

Has your child previously been to a dentist?

Yes No

Name and location of dentist

How long since the last dental visit?

Date of last cleaning

Date of last x-rays

Has your child ever had an unpleasant dental experience?

Yes No

Describe:

Oral Habits

Has your child ever had any of the following habits?

(please indicate ages when the habit occurred)

Use of a pacifier

Yes No

Age?

Thumb or finger sucking

Yes No

Age?

Bottle to bed or nap

Yes No

Age?

Tongue thrusting

Yes No

Age?

Mouth breathing

Yes No

Age?

Teeth grinding

Yes No

Age?

Oral Hygiene and Diet

How often are your child’s teeth brushed?

Does a parent or adult routinely assist with brushing?

Yes No

If so, who and how often?

Does your child’s toothpaste contain fluoride?

Yes No

Is your tap water at home provided by a community water supply (compared to other sources such as private well water)?

Yes No

Does your child take any additional fluoride supplementation (such as prescription drops or tablets)?

Yes No

Does your child use floss?

Yes No

How often?

Does your child use mouthrinse?

Yes No

What kind and how often?

What are your child’s favorite snack foods?

What liquids does your child typically consume?

History of Dental Injuries

Has your child ever experienced a dental injury?

Yes No

Involved teeth/location

When?

Describe the cause

Treatment

Fun Facts

What would you like to see in your dentist?

School/Grade Level

Brothers or Sisters

Favorite Hobby/Sport

Favorite Food

Favorite Animal

Musical Instruments Played

Any other information you would like us to know?

Authorization

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent or Guardian:

Clear

Clear

Online Signature×

Draw your signature inside the box Clear