Child'S Dental Health History Form
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1
2Health History Form
Print this form, complete all information, and bring it with you on your first visit to our office.
The parent or Guardian who
For your convenience…
accompanies the child is responsible for payment at the time of service.
Tell Us About Your Child
Who is Accompanying the Child Today?
1.
5.
Child’s Name ________________________________________
Name _______________________________________________
Last
First
M
I
Relationship__________________________________________
Nickname______________________
Male
Female
Do you have legal custody of this child?
Yes
No
Siblings that we treat __________________________________
Child’s Birthdate _____/_____/_____ Child’s Age ___________
Person Responsible for Account
6.
Child’s Home # (__________)___________________________
Name_______________________________________________
SS#________________________________________________
Relationship__________________________________________
Child’s Home Address:_________________________________
Billing Address _______________________________________
___________________________________________________
____________________________________________________
City
State
Zip
City
State
Zip
Home # (____________)________________________________
Work # (____________)________________________________
Who may we thank for referring you to our office?
2.
Cellular # (___________)________________________________
___________________________________________________
E-mail ______________________________________________
___________________________________________________
Primary Dental Insurance
7.
Mother’s Information
3.
Insurance Co. Name ___________________________________
Insurance Co. Address _________________________________
Name ______________________________________________
____________________________________________________
Mother
Stepmother
Guardian
Birthdate _____/_____/_____
Insurance Co. Phone # (___________)_____________________
Group # (Plan, Local, or Policy #) _________________________
Employer ___________________________________________
Policy Owner’s
Name __________________________________
Work # (_________)____________________ Ext. __________
Relationship to Patient__________________________________
Home # (_________)__________________________________
Policy Owner’s
Birthdate ______/ ______/ ______
Cellular Phone # (_________)___________________________
Social Security # ______________________________________
Policy Owner’s
Employer _______________________________
SS # _____________________ DL# _____________________
Secondary Dental Insurance
Father’s Information
4.
8.
Insurance Co. Name ___________________________________
Name ______________________________________________
Insurance Co. Address _________________________________
____________________________________________________
_____
Father
Stepfather
Guardian
Birthdate _____/_____/
Insurance Co. Phone # (___________)_____________________
Employer ___________________________________________
Group # (Plan, Local, or Policy #) _________________________
Policy Owner’s
Name __________________________________
Work # (_________)____________________ Ext. __________
Relationship to Patient__________________________________
Home # (_________)__________________________________
Policy Owner’s
Birthdate ______/ ______/ ______
Cellular Phone # (_________)___________________________
Social Security # ______________________________________
SS # _____________________ DL# _____________________
Policy Owner’s
Employer _______________________________
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Parent category: Medical