Home
About us
Vision
Services
Doctors & Team
Office
First visit
First visit experience
Appointment request
Parent info
Forms
New Patient Registration Form
Medical Update (12yrs & under) form
Medical Update Teen (13 yrs +) form
SDF consent form
Appointment
Doctor Referral
New patient
Existing patient
Contact
Menu
Home
About us
Vision
Services
Doctors & Team
Office
First visit
First visit experience
Appointment request
Parent info
Forms
New Patient Registration Form
Medical Update (12yrs & under) form
Medical Update Teen (13 yrs +) form
SDF consent form
Appointment
Doctor Referral
New patient
Existing patient
Contact
Home
About us
Vision
Services
Doctors & Team
Office
First visit
First visit experience
Appointment request
Parent info
Forms
New Patient Registration Form
Medical Update (12yrs & under) form
Medical Update Teen (13 yrs +) form
SDF consent form
Appointment
Doctor Referral
New patient
Existing patient
Contact
Child’s Full Name
*
Date of Birth
*
Child’s Physician/Pediatrician
*
Physician’s Phone Number
*
Is your child in good health?
*
Yes
No
Is your child presently under the care of a physician for any medical reason?
*
Yes
No
Please explain
*
Has your child ever been hospitalized or had surgery?
*
Yes
No
Please explain
*
Is your child currently taking any medications?
*
Yes
No
Please specify
*
Are there any allergies or reactions?
*
Yes
No
If yes, a list of allergies will appear. Check any applicable allergie(s)
Please list
*
Aspirin
Pollen/Dust
Local Anesthetics
Penicillin or other antibiotics
Food
Dyes
Latex
Metals
Other
Please list foods your child is allergic to
*
Other? Please list
*
Have you ever been diagnosed as having any conditions?
*
Yes
No
If yes, a list of conditions will appear. Check any applicable condition(s)
Please list
*
Autism Spectrum Disorder
Anxiety/Depression
ADD/ADHD/ODD
Asthma/Breathing Problems
Acid Reflux/Stomach Issues
Birth Defect or Syndrome
Bladder/Kidney Problem
Blood Disorders
Bone or joint problems
Cancer/Tumor
Cerebral Palsy
Chronic Ear Infections
Hearing/Speech Impairment
Cleft lip/palate
Convulsion/Seizures
Delayed growth/Problem Stature
Development birth defect /syndrome
Diabetes
Disability/Physical
Down Syndrome
Eating Disorders
Eye Problems
Emotional Disturbance
Heart Problem/Surgery
Headaches/Migraine
Spina Bifida
Heart Murmur
Hemophilia
HIV/AIDS
Hormonal Issue (Thyroid)
Learning Disability
Oral Ulcers
Premature Birth
Sickle cell anemia
Sleep Apnea/Snoring
Skin Issues
Malignant Hyperthermia
Family history of Malignant Hyperthermia
Other
Other? Please list
*
I give consent to the Kids & Teens Dental to text and email office correspondence including, appointment reminders, account statements and general practice information.
*
Yes
The permission of parent or guardian is necessary for dental treatment of a minor.
*
I understand that all the above information I have given is correct and accurate; that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.
Parent name
*
Signature
*
Relationship to Child
*
Date
*
Notice
*
Signature
*
Phone
Submit
