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 *