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We Want to Know All About You

We are a chartless office and when you come to your appointment we will have you fill out detailed information about the patient in the computer. In order to have your wait time as short as possible, please fill out this form with insurance, patient family and general information and submit it to our office so we may enter this information beforehand. We look forward to seeing you at your appointment.

 
New Patient Family Information
Patient's Name *
Patient's Name
Patient's Birth Date
Patient's Birth Date
Gender *
Street Address
Street Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Alternate Parent's Phone Number *
Alternate Parent's Phone Number
Alternate Parent's Name *
Alternate Parent's Name
Responsible Party's Name/Guardian *
Responsible Party's Name/Guardian
In case of emergency (someone that does NOT live with child) *
In case of emergency (someone that does NOT live with child)
In Case of Emergency Phone *
In Case of Emergency Phone
Insurance Information
Policy holder's name *
Policy holder's name
Policy holder's DOB *
Policy holder's DOB
Policy holder's address (if different from child) *
Policy holder's address (if different from child)
Policy holder's phone number *
Policy holder's phone number
Insurance Phone Number *
Insurance Phone Number
PATIENT CLINICAL FORM
Patient's Name *
Patient's Name
Parent's Marital Status *
Is your child adopted? *
If yes, do you have legal documentation? *
Pediatrician's Phone Number: *
Pediatrician's Phone Number:
Mom's Dental Health
Dad's Dental Health *
Does your child play contact sports?
If so, do they wear a mouthguard? *
Does your child brush his/her own teeth? *
Does your child use dental floss? *
Are you currently nursing your child? *
Does your child use fluoride products? (Check all that apply)
Please estimate your child's daily exposure to the following items:
For your upcoming visit...
Has your child had problems with any of the following (please check all that apply)