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Child Form

Tell Us about Your Child:
Child's name:
Child's birthdate (day/month/year): / /
Child's age:
Nickname:
Gender: male female
School:
Hobbies:
Child's Home #:
Social Security #: - -
Child's Home Address:
   
General Information:
Who will be accompanying the child? Name:
Relation:
Do you have leagal custody of the child? yes no
Other siblings:
Whom may we thank for referring you?
   
Parent's Information:
Person responsible for this account:
   
  Father Step Father Guardian
Name
Birthdate

/ /

Address
(if different than Child)
Social Security #:

- -

Work Phone #: ( ) -
Email
Employer
Employer's Address
 
Dental Insurance Co. Name
Insurance Address
Insurance Phone Number
Group # (Plan, Local or Policy #)
   
  Mother Step Mother Guardian
Name
Birthdate

/ /

Address
(if different than Child)
Social Security #:

- -

Work Phone #:

( ) -

Email
Employer
Employer's Address
 
Dental Insurance Co. Name
Insurance Address
Insurance Phone Number
Group # (Plan, Local or Policy #)
   
Release:  

I certify that my child is covered by Insurance Co. and I assign all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying all copayments and deductibles that my insurance does not cover. 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.

Name of Parent or Guardian:

   
Dental History:  
Why did you bring the child to the dentist today?
Is your child currently in pain? yes no
Does your child require antibiotics before dental treatment? yes no
Has your child ever had a serious/difficult problem associated with previous dental work? yes no
Is your child’s water fluoridated? yes no
Floss his/her teeth daily? yes no
Has your child ever had any pain / tenderness in his/her jaw joint (TMJ/TMD)? yes no
Does your child brush his/her teeth daily? yes no
Child's Physician
Phone #:
Is your child currently under the care of a physician? yes no
 

Please list all prescriptions/ over the counter or herbal supplement drugs that your child is currently taking:

 

Please list all drugs and things your child is allergic to:

   
Is your child allergic to:  
yes no
Latex
yes no
Metals/Nickel
yes no
Plastic
   
Dental History: Has your child experienced the following medical problems?
yes no
Abnormal Bleeding/Hemophilia
yes no
ADD/ADHD
yes no
AIDS/HIV
yes no
Anemia
yes no

Any hospital stays/operations,
if so please explain

yes no
Artifical Bones/Joints/Valves
yes no
Asthma
yes no
Cancer
yes no
Chicken Pox
yes no
Congenital Heart Defects
yes no
Convulsions
yes no
Diabetes
yes no
Epilepsy
yes no
Handicap/Disabilities
yes no
Hearing Impairment
yes no
Heart Murmur
yes no
Hepatitis
yes no
High Blood Pressure
yes no
Kidney Problems
yes no
Liver Problems
yes no
Low Blood Pressure
yes no
Lupus
yes no
Measles
yes no
Mitral Valve Prolapse
yes no
Mononucleosis
yes no
Rheumatic Fever
yes no
Scarlet Fever
yes no
Tuberculosis (TB)
yes no
Is there anything you would like to discuss with the Doctor in private?
  Is there anything else you would like us to know about your child’s medical history? If so, please explain.
   

Does/did you child experience any of the following?
yes no
Chewing on objects
yes no
Clenching/Grinding Teeth
yes no
Mouth breather
yes no
Nursing bottle habit
yes no
Speech Problems
yes no
Thumb or Finger Sucking
yes no
Used or uses a pacifier
   

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest 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 that my child may need.

Name of Parent or Guardian:

   
 

Seville Family Dentistry
3336 E. Chandler Heights Road
Building 3, Suite 119
Gilbert, AZ 85297

(480) 279-4790