Patient's Full Name Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 Patient Birthdate

Select One... Male Female Male / Female Nickname Current Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 Age

Address City/State/Zip

Home Phone Last Dental Visit Special Interests

Grade Siblings Pets

Who may we thank for referring you to our office?

Patient's Appointment Date:  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2007 2008 2009 2010 2011 2012 2013

 Account Information

Responsible Party 1 SSN

Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 Birthdate Choose One Father Mother Stepfather Stepmother Grandparent Legal Guardian Other Self Spouse Relationship to Patient

Address City / State / Zip

Home Phone Work Phone Cell

Employer Job Title

Employer Address Employer City / State / Zip

Responsible Party 2 SSN

Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 Birthdate Choose One Father Mother Stepfather Stepmother Grandparent Legal Guardian Other Self Spouse Relationship to Patient

Address City / State / Zip

Home Phone Work Phone Cell

Employer Job Title

Employer Address Employer City / State / Zip

Email Address

Insurance Information

Check if you do not have dental insurance.

Check if you have dual insurance (ie: both parents have insurance). Please complete this section twice.

Insured Social Security Number

Birth Month January February March April May June July August September October November December Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 Birthdate Choose One Father Mother Stepfather Stepmother Grandparent Legal Guardian Other Self Spouse Relationship to Patient

Address City / State / Zip

Home Phone Work Phone Cell

Employer Job Title

Employer Address Employer City / State / Zip

Insurance Company Insurance Co Phone #

Dental Claim Address City / State / Zip

Group Number Policy Number

Union Name Local

Dental & Medical History

Previous Dentist Name Phone

Physician Name Physician Phone

If any of the below apply please check the corresponding boxes and explain in spaces provided.

Check if patient requires pre-medication prior to routine dental procedures.

Current Dental Problems? Explain:

Any injuries to teeth or head? Details:

Any unfavorable dental experience? Explain:

Any sensitivity to temperature or pressure?

Any thumb or tongue habits?

Mouth Breather?

Currently under medical treatment? Condition:

Currently taking any medications? List:

Ever been hospitalized? Reason & Date:

Ever had a serious head injury? Details:

Allergies: Penicillin Sulfa Drugs Pain Medications Local Anesthetic Aspirin Latex

Other Allergies:

Conditions:

Heart Condition Hepatitis Seizure Disorder Liver Disease Heart Defects at Birth

Diabetes Ear Infections Mitral Valve Prolapse Asthma Learning Disorder Kidney Disease

Anxiety Disorder Pregnancy Respiratory Disease Tuberculosis AIDS Related Complex

Strep Throat Tumor/Growths Jaundice Hearing Impairment Vision Impairment

Rheumatic Fever Blood Disease HIV Positive Growth Disorder Arthritis/Joint Pain

Prolonged Bleeding Behavior Disorder ADD/ADHD PDD Autism Spectrum Disorder

Other Conditions:

Vaccinations/Immunizations Up-to-date   Chickenpox Vaccine

By clicking the "Submit" button below I am indicating that I am the legally responsible party, that I authorize treatment to be rendered by Kids Dentist, PC, and that I will keep them informed of any changes to the information provided here. I further authorize Kids Dentist, PC to submit insurance claims on my behalf, if applicable, and assume financial responsibility for the total fee charged.