Pi 209

49050 Schoenherr Rd.
Suite # 400
29421 Ryan Road
Shelby Twp, MI 48315
Warren, MI 48092
(586) 247-5544
(586) 754-6300
kspdonline.com
pdconline.com
PATIENT INFORMATION
CHILD’S FULL NAME: _________________________________________________________ NICK NAME: ______________________________________ CHILD’S BIRTH DATE: _________________________________________ AGE: ____________________________________ SEX: (Circle) M F CHILD LIVES WITH: (Circle) Both Parents Mother Father Guardian Grandparents
CHILD’S HOME ADDRESS:_____________________________________ CITY: ______________________________________ ZIP: _________________ HOME PHONE: ________________________________________________ CELL PHONE: ___________________________________________________ EMAIL ADDRESS: ___________________________________________________________ ALTERNATE NUMBER - Emergency
(Friend, neighbor, relative, etc.) Name: ________________________________________________ Relationship to Child: _______________________ Phone: _______________________ REFERRAL SOURCE
We appreciate the referral of patients to our office and like to send a special “thank you”. Whom may we thank for referring you to us? Name: ___________________________________________________ Relationship: _________________________________________________________ PARENT INFORMATION
FATHER’S FULL NAME: _______________________________________ MOTHER’S FULL NAME: _______________________________ Father Employed By:__________________________________________ Mother Employed By:___________________________________ Social Security #: ____________________________________________ Social Security #: ______________________________________ Driver’s License # _______________________________________ Driver’s License #: _____________________________________ Employer Phone #:_____________________________________ Employer Phone #:_____________________________________ Birth Date: ___________________________________________ Birth Date: ___________________________________________ DENTAL INSURANCE INFORMATION
Insured Party’s Name:_________________________________________ Relationship to Child: ___________________________________ Employer: __________________________________________________ Insurance Co.: ________________________________________ Group #: ___________________________________________________ Insurance Phone #: ____________________________________ Contract # ____________________________________________ IF MORE THAN ONE INSURANCE COVERAGE, PLEASE COMPLETE: Insured Party’s Name: __________________________________ Relationship to Child: ___________________________________ Employer: ____________________________________________ Insurance Co.: ________________________________________ Group #: _____________________________________________ Contract #: ___________________________________________ Insurance Phone #: ____________________________________ Payment for services is required at each appointment.
The adult who brings the child to the office is financially responsible.
It is your responsibility to inform us of any changes in your child’s health. Thank you.
Family Physician or Pediatrician: ______________________________________ Phone: ____________________________ MEDICAL HISTORY
CONDITION
CONDITION
CONDITION
Please explain any YES answersor other health problems: ■ Amoxicillin ■ Medicine ■ None Known ■ Other / List: ____________________________________________________________ Is your child taking any medicine now: (Circle) YES NO ____________________________________________________________________ Is your child being seen by a physician? (Circle) YES NO If yes, why ________________________________________________________________ DENTAL HISTORY
Does your child have a toothache now? (Circle) YES NO Where: __________________________________________________________________ Any previous dental experience? (Circle) YES NO Where: __________________________________________________________________ What was done: __________________________________ __________________________________________________________________ Child’s reaction: __________________________________ Parent’s reaction: __________________________________________________________ ________________________________________________________________________________________________________ Any injuries to front teeth? (Circle) YES NO __________________________________________________________________ Has your child ever had injuries to the head or neck? (Circle) YES NO Does your child have any oral habits? (Circle) Thumb Finger Pacifier Other: __________________________________________________________ Who brushes your child’s teeth? ______________________ __________________________________________________________________ Reason for today’s appointment? ________________________________________________________________________________________________ Name and ages of other children in the household: __________________________________________________________________________________ DIETARY HISTORY
Does your child snack frequently?: (Circle) YES NO On what? ____________________________________________________________________ Does your child drink juice frequently?: (Circle) YES NO What kind? ________________________________________________________________ Many fruit juices have natural acids which can cause cavities if taken frequently. Does/did your child take a bottle to bed? (Circle) YES NO Explain:__________________________________________________________________ Because your child is a minor, signed permission is required from a parent or guardian for any dental treatment.
Signature of parent or guardian: __________________________________________________________ Date: ________________________________ Reviewed by: __________________________________________________________________________ Date: ________________________________

Source: http://www.pdconline.com/wp-content/uploads/2011/08/151390-New-Patient-Form-PI-2091.pdf