Gentle Care of Precious Young Smiles

New Patient Form

Patient Information:
Child's Full Name		Preferred Name
Sex	M F	Date of Birth		Age
Child's Address		City		State	Zip
Home Phone
Patient's School		Grade Level
Patient's Hobbies/Pets
Names and ages of siblings
Is the child adopted?	Y N	If yes, does the child know?	Y N
Person filling out this form		Relationship to Child
How did you find out about us

Responsible Party:
Name		Relationship to Child
Phone Number
Address
City
State
Zipcode

Parent or Guardian Information:
Role:	Father Stepfather Guardian (check one)
Full Name		Date of Birth
Address		City		State	Zip
Marital Status	Single Married Separated Divorced (check one)
Home Phone		Cell Phone		Business Phone
Email
Employer		Occupation
Dental Insurance:	Y N
Insurance Company Name		Primary	Y N
Insurance Co. Policy or Group Number		Employee Number
Insurance Co. Phone		Address
City
State
Zip

Parent or Guardian Information:
Role:	Mother Stepmother Guardian (check one)
Full Name		Date of Birth
Address		City		State	Zip
Marital Status	Single Married Separated Divorced (check one)
Home Phone		Cell Phone		Business Phone
Email
Employer		Occupation
Dental Insurance:	Y N
Insurance Company Name		Primary	Y N
Insurance Co. Policy or Group Number		Employee Number
Insurance Co. Phone		Address
City
State
Zip

Emergency Contact:
Name		Relationship to Child
Home Phone		Cell Phone		Work Phone

Medical History:
Has your child ever had any of the following:
Aids/HIV Abnormal Bleeding Allergy to Latex Allergy to Penicillin Allergy to Other Drugs Describe: Anemia Anxiety Asthma Autism Attention Deficit Disorder Bone Disorder Brain Injury Bronchitis Cancer Cerebral Palsy Chicken Pox Cleft Lip/ Palate Communicable Disease Physical Disability Psychiatric Disorder	Convulsion/ Seizure/ Epilepsy/ Fainting Developmental Delay Diabetes Drug or Alcohol Abuse Eating Disorder Endocrine/ Growth Disorders Eye Problems Hearing Problems/ Loss Heart Disease/ Murmur Hemophilia Hepatitis/ Liver Problems Hyperactivity Jaundice Kidney Problems Leukemia Measles Mumps Mental Disorder/ Handicap Pneumonia Panic Attacks	Rheumatic Fever Radiation Treatment Scarlet Fever Sickle Cell Anemia Sickle Cell Trait Sinus Problems/ Snoring Enlarged Tonsils/ Adenoids Seasonal Allergies Speech Problem/ Delay Tuberculosis Premature birth Age at Birth: Other Please explain: This child has never had any of the above conditions.
Child's Physician's Name
Phone
Address
City
State
Zip
Date of last visit
List any medical problems, hospitalizations, surgeries, emergency room visits
List all medications (including dosage) the child is taking and why
Is premedication needed prior to dental treatment?		Why?
Is your child under the care of a specialist?		Why?
Specialist’s Name		Phone
Do you consider your child: (check one)
Advanced in learning process
Progressing normally
A slow learner

Dental History
How often does your child brush?		Floss?
Is brushing/ flossing supervised?		By Whom?
Does your child receive fluoride?
Has your child had any injuries to the face, teeth, or jaw? Please explain:
Has your child had any recent dental pain and where?
Please check any that apply:
Breast/ Bottle Feeding
Mouth Breathing/ Snoring
Grinding
Thumb/ Finger Sucking
Pacifier
Has your child had any unfavorable reactions from previous dental care? Please explain:
Previous Dentist
City
Date of last visit:
Date of last x-rays:

Authorization and Release:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize Dr. Sadrian and staff to perform necessary dental procedures including, but not limited to, the use of nitrous oxide, local anesthetic and take any necessary radiographs to diagnose and/or treat my child’s dental needs. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I also authorize Dr. Sadrian to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other healthcare practitioners. I authorize and request my insurance company to pay directly to the dentist or dentist’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependants.
Parent/ Guardian: Date:

Authorization and Release:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize Dr. Sadrian and staff to perform necessary dental procedures including, but not limited to, the use of nitrous oxide, local anesthetic and take any necessary radiographs to diagnose and/or treat my child’s dental needs. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I also authorize Dr. Sadrian to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other healthcare practitioners. I authorize and request my insurance company to pay directly to the dentist or dentist’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependants.

Parent/ Guardian: Date: