Pediatric New Patient Form

Click here for the paper form.

Name *
Birthdate *
Does the patient attend school?
Physician's Phone Number
Physician's Phone Number
Address of Physician
Address of Physician
Pharmacy Phone Number
Pharmacy Phone Number
Mother's Full Name *
Mother's Full Name
Mother's Date of Birth *
Mother's Date of Birth
Mother's Address *
Mother's Address
Mother's Phone Number *
Mother's Phone Number
Father's Full Name *
Father's Full Name
Father's Date of Birth *
Father's Date of Birth
Father's Address *
Father's Address
Father's Phone Number *
Father's Phone Number
Who does the child live with? *
Insurance Coverage Information
Policyholder's Date of Birth *
Policyholder's Date of Birth
I certify the insurance information listed above is the patient’s primary dental insurance plan. *
Appointment Reminders
Email and/or Text *
Phone to Text *
Phone to Text
How did you hear about us? *
Health History
Heart *
Kidney *
Liver/GI *
Endocrine System *
Lung/Breathing *
Neurological *
Hearing/eye *
Dermal/musculoskeletal *
Sleep related breathing problems *
Does the patient have any disease, condition, syndrome or other health problem not listed previously? *
Is the patient in good health? *
Is he/she up to date with immunizations? *
Has he/she been hospitalized since birth? *
Is the patient currently taking any medications? *
Is the patient allergic to any medications or drugs? *
Is he/she presently receiving medical treatment? *
If applicable, Is the patient pregnant or thinks she is pregnant? *
If applicable, is the patient taking birth control? *
If applicable, does the patient smoke? *
If yes, how much does the patient smoke a day?
Dental History
Date of patient's last dental visit *
Date of patient's last dental visit
Were X-rays taken? *
Has patient had any unhappy dental experiences? *
Has patient had any unhappy dental experiences? *
Does the patient have a toothache? *
Does the patient have any jaw pain? *
Does patient have any mouth habits (thumb/finger sucking, pacifier, grinding, etc.)? *
Does patient brush daily? *
Does patient use floss? *
What type of water is typically used for brushing, cooking, drinking? *
Does an adult assist with home dental care? *
Is there any additional information that you feel might be of value to us? *
Date *

Referral Form

To refer a patient for a consultation, please complete the form below. Your patient can contact our office and set a convenient appointment time. We will keep you informed of the patient’s treatment plan and progress. Thanks so much for your referral! Click here for the paper form.

Referral Date *
Referral Date
Referring Doctor *
Referring Doctor
Patient's Name *
Patient's Name
Date of Birth *
Date of Birth
Parent's Name *
Parent's Name
Best Phone Number *
Best Phone Number
In order to best serve your family, we are referring you to a specialist

Patient Survey

Patient Name (Optional)
Patient Name (Optional)
How would you rate your visit overall (4 being the highest)?
When your appointment was over did you have a good understanding of your dental situation?
Were your financial options explained to you?
Were you pleased with the dental treatment that your child received?
Would you refer your family and friends to us?

 History and Eval Form

Click the button below for the printed history and eval form.