Fill Out the Welcome & Medical History Form Below Step 1 of 2 50% Welcome FormPatient First Name* Patient Last Name* Nickname Date of Birth* MM slash DD slash YYYY Sex* Patient SSN Primary ResidenceAddress* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* Home Phone #Cell Phone #*Email* School* Grade* Sibling(s) Name(s) Parent/Guardian's InformationMarital Status* Married Single Divorced Separated Parent 1 Name* Relationship to child* Date of Birth* MM slash DD slash YYYY Address Same as Child Different from Child If different from child... Cell Phone #*Home Phone #Email* Employer* SSN* Driver's License #* Parent 2 Name* Relationship to Child* Date of Birth* MM slash DD slash YYYY Address Same as Child Different from Child If different from child... Cell Phone #*Home Phone #Email* Employer* SSN* Driver's License #* Is the responsible party different from above?* Yes No Responsible Party Name (if different from above)* Relationship to Child* Date of Birth* MM slash DD slash YYYY Address Yes No If different from child... Cell Phone #*Home Phone #Email* Employer* SSN* Driver's License #* Primary Dental Insurance InformationDo you have dental insurance? Yes No Insurance Company Name Insurance Phone #Employer Name Policy Effective Date MM slash DD slash YYYY Subscriber/Employee Name Member ID # Group # Subscriber's Date of Birth MM slash DD slash YYYY SSN Relationship to Patient Address Same as Child Different from Child If different from child... Secondary Dental Insurance InformationDo you have a secondary dental insurance plan? Yes No Insurance Company Name Insurance Phone #Employer Name Policy Effective Date MM slash DD slash YYYY Subscriber/Employee Name Member ID # Group # Subscriber's Date of Birth MM slash DD slash YYYY SSN Relationship to Patient Address Same as Child Different from Child If different from child... Getting to Know YouHow did you hear about us?* Billboard TV School Visit Radio Facebook Letter Family/Friend Postcard Internet Sign/Drive-by Event Other If other: Who may we thank for referring you? Other family members/friends seen by us: At Your Child's Visit We invite you to stay with your child during his or her first visit and the initial examination; however, we want to give your child our full attention and have his or hers as well, so we ask that parents/legal guardians act as “silent observers” during the visit. Cooperation and trust must be established between the doctor and your child. This allows the doctor and staff to communicate with your child directly without distractions or safety concerns. Due to limited space, we ask that one parent accompany the child back and all siblings remain in the waiting area with a responsible adult. If no adult is available, we will bring the child back on their own and consult with the parent after our exam. There may be times when a child’s experience is enhanced by a parent’s absence, in which case we may ask the parent to wait outside in order to facilitate a more direct line of communication between the doctor and the child. Our goal is to make your child’s dental visit a safe and positive one. We thank you for your understanding and cooperation.I understand the above statement regarding the proper expectations during my child's visit:* Consent for Treatment I certify that the above information is complete and accurate to the best of my knowledge. I hereby authorize Hudsonville Dental Kids and staff to take x-rays, photos, and other diagnostic aids as deemed appropriate by the Doctor to make a thorough diagnosis of my child’s needs. I authorize Hudsonville Dental Kids to use my photographs and x-rays for research, marketing, education, or publication in professional journals. I fully understand that using anesthetic agents embodies certain risks. I understand I may ask for complete recital of any complications. I have received a copy of this office’s HIPAA policy or had the opportunity to do so. Lastly, I agree to be responsible for payment of services rendered on my child. I understand payment is due at time of service unless other arrangements have been made. If payments are not paid by agreed dates, I understand a 12% finance charge will be added on my account.Signature of Parent/Legal Guardian* Reset signature Signature locked. Reset to sign again Printed Name* Date* MM slash DD slash YYYY Medical History FormPatient Name* Date* MM slash DD slash YYYY Has Your Child Ever Had Any Of The Following Conditions:ADD/ADHD* Yes No AIDS/HIV* Yes No Asthma* Yes No Autism* Yes No Cancer/Leukemia* Yes No Cerebral Palsy* Yes No Chemotherapy/Radiation* Yes No Congenital Birth Defects* Yes No Development Delay* Yes No Diabetes* Yes No Down Syndrome* Yes No Emotional/Mental Disabilities* Yes No Epilepsy/Seizures or Fainting* Yes No Eyesight Problems* Yes No G-Tube* Yes No Hearing Loss* Yes No Heart Conditions* Yes No Infections* Yes No Lupus* Yes No Rheumatic Fever* Yes No Second Hand Smoke* Yes No Other Conditions: Allergies:Amoxicillin* Yes No Aspirin* Yes No Codeine* Yes No Dental Anesthetics* Yes No Erythromycin* Yes No Latex* Yes No Metals* Yes No Penicillin* Yes No Red Dye* Yes No Seasonal/Environmental* Yes No Sulfa* Yes No Tetracycline* Yes No Other Allergies: Dental Questionnaire:1. Is this your child's first visit to a dentist?* Yes No 2. If yes, what are your child's feelings toward their first dental visit? (Check all that apply) Excited Nervous Anxious Other If other, please explain: 3. If no, has your child had any problem with dental treatment in the past? Yes No I don't know If yes, please explain: 4. When was their last check up?* MM slash DD slash YYYY a. Previous Dentist's Name: Previous Dentist's Phone #:5. Were radiographs or photos taken when your child was last at the dentist?* Yes No 6. Is your child in orthodontics?* Yes No a. Orthodontist's Name: 7. Does your child snack between meals?* Yes No a. If yes, how often? 8. Does your child eat sweets or drink juice?* Yes No a. If yes, how often? 9. Does your child use a sippy cup, a pacifier, and/or suck thumb/fingers?* Yes No 10. When does you child brush his/her teeth? (Check all that apply)* In the morning After eating any food After meals In the evening 11. Have any cavities been noted in the past?* Yes No I don't know 12. Have there been injuries to teeth, such as falls, blows, chips, etc?* Yes No I don't know If yes, please explain: Medical Questionnaire:1. Is your child under the care of a physician or a specialist?* Yes No a. If yes, please explain: 2. Has the child been hospitalized for any surgical operation or serious illness within the last 5 years?* Yes No If yes, please explain: 3. Has he/she been out of the country in the last 3 weeks?* Yes No a. If yes, have they been sick or felt under the weather? Yes No 4. Is your child taking any medication(s) including prescriptions, non-prescriptions, supplements, and vitamins? Please list.5. Does your child have sleep apnea?* Yes No 6. Other Comments:7. Physician's Name* a. Physician's Phone #*8. Preferred Pharmacy a. Pharmacy Phone #Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. If a medical emergency arises in the office, a complete medical history is needed to provide you with the best care and efficiency. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental 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 or my dependents.Signature of Parent/Legal Guardian/Patient* Reset signature Signature locked. Reset to sign again Printed Name* Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
