Welcome Children Form

Name of Minor/Child

Last Name

First Name

Initial

Sex

M

F

Age

Birthdate

Nickname

Hobbies

Home Address

Street

City

State

Zip

Person financially responsible

Home Phone

Work Phone

Whom may we thank for referring you?

Father's/Guardian's Name

Address (if different from patient's)

Home Phone

(if different from above)

Work Phone

(if different from above)

Employer

Soc. Sec #

Birthdate

Do you have dental insurance coverage for minor/child?

Yes

No

Plan Name

Phone #

Address

Group #

Policy #

Mother's/Guardian's Name

Address (if different from patient's)

Home Phone

(if different from above)

Work Phone

(if different from above)

Employer

Soc. Sec #

Birthdate

Do you have dental insurance coverage for minor/child?

Yes

No

Plan Name

Phone #

Address

Group #

Policy #

Is your child eligible for treatment under Medical Assistance?

Yes

No

Child's Medical Assistance I.D. #

Date of last visit to a dentist

For what service?

Any mouth habits i.e. thumb sucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?

Yes

No

Minor/Child's Physician

City/State

Phone

Date of last physical examination

Results

HAS MINOR/CHILD HAD ANY HISTORY OF OR DIFFICULTY WITH ANY OF THE FOLLOWING? IF YES, PLEASE CHECK

A.I.D.S./H.I.V.

Anemia

Asthma

Bladder Problems

Cancer

Cerebral Palsy

Chicken Pox

Convulsions

Diabetes

Drug/Alcohol Abuse

Epilepsy

Fainting

Hearing Problems

Heart Problems

Hepatitis

Kidney Disease

Liver Disease

Measles

Mononucleosis

Mumps

Rheumatic Fever

Sinus Problems

Thyroid Disease

Tuberculosis

Other

In the event of an emergency, whom should we contact?

Name

Relationship

Phone

Name

Relationship

Phone

The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services for my minor/child.

Signature of Parent/Guardian

Date

I certify that my minor/child is covered by insurance with, Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature of Parent/Guardian

Date

(To be completed at a later visit)

Has there been any change in patient's health since last dental appointment?

Yes

No

If yes, please describe

Is patient taking any new medications?

Yes

No

If yes, please describe

Date

Parent/Guardian Signature

Date

Dentist Signature