Child Dental Health History Form - Northwest Children'S Dentistry
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1
2Health History Form
Norman Bunch, DDS, MS & Jennifer Marshall, DDS, MSD
7610 N. La Cholla Blvd. Tucson, AZ 85741
Phone: (520) 544-8522 Fax: (520) 877-7703
For your convenience… Print this form, complete all information, and bring it with you on your first visit to our office. The Parent or Guardian who
accompanies the child is responsible for payment at the time of service.
1.
Tell Us About Your Child
4. Who is Accompanying the Child Today?
Child’s Name
Name
Relationship
Last
First
MI
Nickname ___________________
Male
Female
Do you have legal custody of this child?
Yes
No
Siblings that we treat
5. Person Responsible for Account
Child’s Birth date ____/_____/_____ Child’s Age
Name
Child’s Home # (________)
Relationship
Child’s Home Address
Billing Address
Apt./Condo
City
State
Zip
Home # (_______)
Work # (_______)________________ Ext.
City
State
Zip
How did you hear about us?
E-Mail
(Please let us know so we can thank them)
6.
Primary Dental Insurance
2.
Mother’s Information
Insurance Co. Name
Name
Insurance Co. Address
Stepmother
Guardian
Birth date ____/_____/
Employer
Insurance Co. Phone #(_______)
Occupation
Group # (Plan, Local, or Policy #)
Work # (________)________________ Ext.
Policy Owner’s Name
Home #(________)
Policy Owner’s Birth date ______/_______/
Cellular Phone #(________)
Social Security #
-
-
Member ID #
Policy Owner’s Employer
3. Father's Information
Name
7. Secondary Dental Insurance
Stepfather
Guardian
Birth date ____/_____/
Insurance Co. Name
Employer
Insurance Co. Address
Occupation
Work # (________)________________ Ext.
Insurance Co. Phone #(_______)
Home # (________)
Group # (Plan, Local, or Policy #)
Cellular Phone # (________)
Policy Owner’s Name
Policy Owner’s Birth date ______/_______/
Parental Marital Status:
Social Security #
-
-
Single
Married
Separate
Member ID #
Widowed
Divorced
Policy Owner’s Employer
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