Child Patient Form

Patients Name
New patient prefers to be called
Patient GenderMaleFemaleOther

Date of birth
             
Do you wish to receive appointment reminders?
 Email
 Text
 Both

Just like phone calls and voicemails, texting may not always be 100% secure depending on the mobile service you use. Knowing that, would you like us to communicate with you via text?
 Yes
 No
 
Approximate date of last visit?
   

Name
Marital StatusSingleMarriedDivorcedWidowedOther
Date of birth
 

Address (If different from above)
Town
StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyoming
     
Do you wish to receive appointment reminders?
 Email
 Text
 Both
   

Name
Marital StatusSingleMarriedDivorcedWidowedOther

Date of birth
 


Address (If different from above)
Town
StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyoming
     
Do you wish to receive appointment reminders?
 Email
 Text
 Both
 

 Primary Dental Insurance
 Dr. Dynasaur/Green Mountain Care
 Children with Special Health Needs

Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Birth Date
   
     

 Secondary Dental Insurance

Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Birth Date
     

 School
 Homeschooled

Hobbies/Interests

Immediate family treated by COA
Siblings & ages

Primary Care Physician
Phone
Last Visit
       
Has the patient tonsils or adenoids been removed?
 Yes
 No

Has the patient experienced jaw joint pain/discomfort? (TMJ/TMD)?
 Yes
 No

Does the patient have missing or extra permanent teeth?
 Yes
 No

Has the patient had an injury to?
 Teeth
 Mouth
 Chin

Does the patient have a history of eating disorders?
 Yes
 No

Does/has the patient had any of the following habits?
 Clenching Teeth
 Lip Sucking/Biting
 Nail Biting
 Prolonged Bottle/Pacifier
 Grinding Teeth
 Mouth Breathing
 Tongue Thrusting
 Thumb/Finger Sucking
 
Is the child allergic to any of the following?
 Aspirin
 Codeine
 Tetracycline
 Metals/Plastics
 Erythromycin
 Penicillin
 Latex
 Other
 No Known Allergies
   

Name
Relationship to patient
Primary Phone