PATIENT INFORMATION

Name: Nickname: DOB: Gender:   M   F
Street Address: City: State: Zip:
Primary number for appointment confirmations:
Who is accompanying the child today or is expected to on the date of their appointment?
Name: Relation: Biological Adopted Foster Nanny Other:

PARENT INFORMATION 

Who does the patient live with? (check all that apply): Guardian 1 Guardian 2 Other:

GUARDIAN (I)

Name: Gender: M F
DOB: SS#:
Marital Status: Single Married Domestic Partnership Separated Divorced Widowed
Home: Cell:
Email:
Yes No  Address is same as patient’s listed above.
Street Address:
City: State: Zip:
Employer:
Work phone:

GUARDIAN (II)

Name: Gender: M F
DOB: SS#:
Marital Status: Single Married Domestic Partnership Separated Divorced Widowed
Home: Cell:
Email:
Yes No  Address is same as patient’s listed above.
Street Address:
City: State: Zip:
Employer:
Work phone:
 

DENTAL INSURANCE INFORMATION

Yes No  Do you have dental insurance coverage?

PRIMARY COVERAGE

Name of Policy Holder:
DOB: SS#:
Employer:
Employer Phone:
Insurance Co.:
Street Address:
City: State: Zip:
Phone:
Group/Policy #:
I.D. #:
   

SECONDARY COVERAGE

Name of Policy Holder:
DOB: SS#:
Employer:
Employer Phone:
Insurance Co.:
Street Address:
City: State: Zip:
Phone:
Group/Policy #:
I.D. #:
   

REFERRAL INFORMATION

Please share with us how you heard about our office…
Sibling(s): Google  
Friend: Website  
Pediatrician/Physician: Facebook  
Dentist/Dental Office: Angie’s List  
Insurance: Print Ad (magazine, newspaper, etc)
School/Daycare: Community Event:
Other:
 

DENTAL HISTORY

DENTAL CONCERNS

What is the primary reason for today’s visit? Cleaning    Trauma/Dental Emergency    Consult for Decay (Cavities) 
Has your child ever been to the dentist? Yes No
(If Yes)
Previous/Present Dentist: Date Last Exam: Date Last X-Rays:
Describe your child:  Outgoing      Shy      Stubborn      Anxious      Frightened      Age appropriate    
How would you expect your child to behave in our office?
How may we help make this visit a positive experience for your child?

DENTAL HABITS

Does your child currently… (check all that apply)
Suck Thumb/Finger   Suck/Bite Lips   Bite/Chew Nails   Bottle Feed Until what age?  
Use Pacifier   Clench/Grind Teeth   Mouth Breather   Breast Feed Until what age?  

HYGIENE ROUTINE

(check all that apply)
Fluoride Toothpaste Consume Fluoridated Water Brushing by Child: / day Brushing by Parent: /day
Fluoride Mouthwash Dental Floss: /week Snack between Meals - Type of snacks:

MEDICAL HISTORY

Are immunizations current? Yes No
Child’s physician: Phone: Date Last Exam:
History of Hospitalizations / Operations / Emergency Room Care / Recent Illnesses (explain):
Current Medications:
 
Has your child been diagnosed and/or treated for any of the following… (check all that apply)
Blood Disorder/Anemia Premature/Low Birth Weight
Abnormal Bleeding/Hemophilia Asthma/Reactive Airway
Immune Disorder/HIV/AIDS Mental/Cognitive/Social Delay
Cancer/Tumor/Leukemia Congenital Birth Defects
Heart Murmur/Defect/Surgery Cleft Lip/Palate
Epilepsy/Seizures/Convulsions Autism Spectrum
Cerebral Palsy ADD/ADHD
Kidney Problems Eating Disorder
Liver Disease/Jaundice/Hepatitis Speech Disorder
Diabetes Vision Problems
Stomach/GI Disorders Hearing Problems/Deaf
 
ALLERGIES:
Medication:
Food:
Seasonal  
Hives  
Latex  
Other (specify):
Comments/Details:
 
 
I affirm the above information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the child's medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I understand Growing Smiles Pediatric Dentistry may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of all information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand I am responsible for the full balance of the account regardless of my dental benefits and directly assign Growing Smiles Pediatric Dentistry all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including but not limited to third party collection fees, court filing fees and attorney fees. I affirm my signature represents my agreement to all of the terms mentioned above.

 
DATE:
RELATIONSHIP TO CHILD
SIGNATURE:
 
 
1111 Cumberland Crossing Drive, Valparaiso, IN P: (219)286.6148 www.growingsmilesvalpo.com