Pediatric Dental/medical History Form
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1
2PEDIATRIC DENTAL/MEDICAL HISTORY FORM
TELL US ABOUT YOUR CHILD
Today's Date:___________
Child's Name:__________________________________ Nickname:_________ [] Male [] Female
LAST
FIRST
MI
Birth Date:___/___/_____ Age: ____ School: __________________________________Grade:______
Child's Home #: (___) ______________ SS#: _____________________
Child's Home Address: _______________________________________________________________
STREET
CITY
STATE
ZIP
WHO IS ACCOMPANYING THE CHILD TODAY?
Name: _________________________ Relation: ________________________
Do you have legal custody of this child? []Yes []No Whom may we thank for referring you? __________
Other family members seen by us: _________________________________________________________
Previous / Present Dentist: ____________________________ Last Visit Date: _____________________
Parent's Marital Status: []Single []Married []Divorced []Separated []Widowed
MOTHER OF CHILD []Step Mother []Guardian FATHER OF CHILD []Step Father []Guardian
Name: ________________________________
Name: _______________________________
Birthdate: ___/___/___ Cell Ph:____________
Birthdate: ___/___/___ Cell Ph:___________
Hm Ph: ____________Wk Ph: _____________
Hm Ph: __________Wk PH: _____________
Employer:_____________ Email:___________
Employer:_____________Email:__________
SS#: _____________ DL#: ________________
SS#: _____________ DL#: ______________
PERSON RESPONSIBLE FOR ACCOUNT
Billing:
Name: ________________________ Relation: __________ SS#: _______________ DL#: __________
LAST
FIRST
MI
Billing Address: ______________________________________________________________________
STREET
CITY
STATE
ZIP
Home #: (____)____________ Employer: _____________________ Work #: (____) _______________
Appointments:
Name: ______________________________ Hm # (___)____________ Wk #: (____)______________
LAST
FIRST
MI
PRIMARY DENTAL INSURANCE
SECONDARY DENTAL INSURANCE
Insurance Co. Name: _____________________
Insurance Co. Name: _____________________
Group #
Group #
(Plan,Local, or Policy #): ________________________
(Plan,Local, or Policy #): _________________________
Address: ______________________________
Address: ______________________________
Phone #: ( ) ____________
Phone #: ( ) ____________
Policy Owner Name: ____________________
Policy Owner Name: ____________________
Relationship to Patient: _______________
Relationship to Patient: _______________
Birthdate: ___/___/___
Birthdate: ___/___/___
SS#: _________ Employer: ______________
SS#: _________ Employer: ______________
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Parent category: Medical