Fill Out Your Child's Welcome & Medical History Form Step 1 of 2 50% Welcome FormPatient First Name*Patient Last Name*NicknameDate of Birth* Date Format: MM slash DD slash YYYY Sex*Patient SSNPrimary 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*MarriedSingleDivorcedSeparatedParent 1 Name*Relationship to child*Date of Birth* Date Format: MM slash DD slash YYYY AddressSame as ChildDifferent from ChildIf different from child...Cell Phone #*Home Phone #Email* Employer*SSN*Driver's License #*Parent 2 Name*Relationship to Child*Date of Birth* Date Format: MM slash DD slash YYYY AddressSame as ChildDifferent from ChildIf different from child...Cell Phone #*Home Phone #Email* Employer*SSN*Driver's License #*Is the responsible party different from above?*YesNoResponsible Party Name (if different from above)*Relationship to Child*Date of Birth* Date Format: MM slash DD slash YYYY AddressYesNoIf different from child...Cell Phone #*Home Phone #Email* Employer*SSN*Driver's License #*Primary Dental Insurance InformationDo you have dental insurance?YesNoInsurance Company NameInsurance Phone #Employer NamePolicy Effective Date Date Format: MM slash DD slash YYYY Subscriber/Employee NameMember ID #Group #Subscriber's Date of Birth Date Format: MM slash DD slash YYYY SSNRelationship to PatientAddressSame as ChildDifferent from ChildIf different from child...Secondary Dental Insurance InformationDo you have a secondary dental insurance plan?YesNoInsurance Company NameInsurance Phone #Employer NamePolicy Effective Date Date Format: MM slash DD slash YYYY Subscriber/Employee NameMember ID #Group #Subscriber's Date of Birth Date Format: MM slash DD slash YYYY SSNRelationship to PatientAddressSame as ChildDifferent from ChildIf 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 Contemporary Family Dental 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 Contemporary Family Dental 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*Printed Name*Date* Date Format: MM slash DD slash YYYY Medical History FormPatient Name*Date* Date Format: MM slash DD slash YYYY Has Your Child Ever Had Any Of The Following Conditions:ADD/ADHD*YesNoAIDS/HIV*YesNoAsthma*YesNoAutism*YesNoCancer/Leukemia*YesNoCerebral Palsy*YesNoChemotherapy/Radiation*YesNoCongenital Birth Defects*YesNoDevelopment Delay*YesNoDiabetes*YesNoDown Syndrome*YesNoEmotional/Mental Disabilities*YesNoEpilepsy/Seizures or Fainting*YesNoEyesight Problems*YesNoG-Tube*YesNoHearing Loss*YesNoHeart Conditions*YesNoInfections*YesNoLupus*YesNoRheumatic Fever*YesNoSecond Hand Smoke*YesNoOther Conditions:Allergies:Amoxicillin*YesNoAspirin*YesNoCodeine*YesNoDental Anesthetics*YesNoErythromycin*YesNoLatex*YesNoMetals*YesNoPenicillin*YesNoRed Dye*YesNoSeasonal/Environmental*YesNoSulfa*YesNoTetracycline*YesNoOther Allergies:Dental Questionnaire:1. Is this your child's first visit to a dentist?*YesNo2. 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?YesNoI don't knowIf yes, please explain:4. When was their last check up?* Date Format: 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?*YesNo6. Is your child in orthodontics?*YesNoa. Orthodontist's Name:7. Does your child snack between meals?*YesNoa. If yes, how often?8. Does your child eat sweets or drink juice?*YesNoa. If yes, how often?9. Does your child use a sippy cup, a pacifier, and/or suck thumb/fingers?*YesNo10. 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?*YesNoI don't know12. Have there been injuries to teeth, such as falls, blows, chips, etc?*YesNoI don't knowIf yes, please explain:Medical Questionnaire:1. Is your child under the care of a physician or a specialist?*YesNoa. If yes, please explain:2. Has the child been hospitalized for any surgical operation or serious illness within the last 5 years?*YesNoIf yes, please explain:3. Has he/she been out of the country in the last 3 weeks?*YesNoa. If yes, have they been sick or felt under the weather?YesNo4. Is your child taking any medication(s) including prescriptions, non-prescriptions, supplements, and vitamins? Please list.5. Does your child have sleep apnea?*YesNo6. Other Comments:7. Physician's Name*a. Physician's Phone #*8. Preferred Pharmacya. 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*Printed Name*Date* Date Format: MM slash DD slash YYYY
