PATIENT INFORMATION
Name:
Nickname:
Date of Birth:
Gender:
Male
Female
Street Address:
City:
State:
Zip Code:
Primary Number for Appointment Confirmations:
Email:
Who is accompanying the child today? Name:
Relation:
Biological Parent
Adopted Parent
Foster Parent
Nanny
Other:
PARENT INFORMATION
Who does the patient live with? (check all that apply):
Guardian 1
Guardian 2
Other:
GUARDIAN (I)
Guardian (I) Name:
Gender:
Male
Female
DOB:
SS#:
Marital Status:
Single
Married
Domestic Partnership
Separated
Divorced
Widowed
Home Phone:
Cell Phone:
Email:
Check if address is the same as patient's listed above.
Street Address:
City:
State:
Zip Code:
Employer:
Work:
GUARDIAN (II)
Guardian (II) Name:
Gender:
Male
Female
DOB:
SS#:
Marital Status:
Single
Married
Domestic Partnership
Separated
Divorced
Widowed
Home Phone:
Cell Phone:
Email:
Check if address is the same as patient's listed above.
Street Address:
City:
State:
Zip Code:
Employer:
Work:
DENTAL INSURANCE INFORMATION
PRIMARY COVERAGE
Name of Insured:
DOB:
SS#:
Employer:
Employer Phone:
Insurance Co.:
Phone:
Street Address:
City:
State:
Zip:
Group/Policy #:
I.D. #:
Please upload a photo or PDF scan of your new insurance card if possible:
SECONDARY COVERAGE
Name of Insured:
DOB:
SS#:
Employer:
Employer Phone:
Insurance Co.:
Phone:
Street Address:
City:
State:
Zip:
Group/Policy #:
I.D. #:
Please upload a photo or PDF scan of your new insurance card if possible:
REFERRAL INFORMATION
Please share with us how you heard about our office...
Sibling(s):
Friend:
Pediatrician/Physician:
Dentist/Dental Office:
Insurance:
School/Daycare:
Other:
Google
Website
Facebook
Angie’s List
Print Ad (magazine, newspaper, etc)
Community Event:
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
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
Use Pacifier
Clench/Grind Teeth
Mouth Breather
Breast Feed:
Bottle Feed:
HYGIENE ROUTINE
(Check all that apply)
Fluoride Toothpaste
Consume Fluoridated Water
Brushing by Child:
Brushing by Parent:
Fluoride Mouthwash
Dental Floss:
Snacks 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
Abnormal Bleeding/Hemophilia
Immune Disorder/HIV/AIDS
Cancer/Tumor/Leukemia
Heart Murmur/Defect/Surgery
Epilepsy/Seizures/Convulsions
Cerebral Palsy
Kidney Problems
Liver Disease/Jaundice/Hepatitis
Diabetes
Stomach/GI Disorders
Premature/Low Birth Weight
Asthma/Reactive Airway Disease
Mental/Cognitive/Social Delay
Congenital Birth Defects
Cleft Lip/Palate
Autism Spectrum
ADD/ADHD
Eating Disorder
Speech Disorder
Vision Problems
Hearing Problems/Deaf
Allergies
(Check all that apply and specify details):
Medication
Food
Seasonal
Latex
Other
Comments/Details:
I affirm that 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 that 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 that 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 that my signature represents my agreement to all of the terms mentioned above.
Date:
RELATIONSHIP TO CHILD:
1111 Cumberland Crossing Drive, Valparaiso, IN
P: (219)286.6148
www.growingsmilesvalpo.com