DYNAMIC PEDIATRIC DENTISTRY FOR CHILDREN, PLC
CINDY WILSON, DDS
CHILD’S REGISTRATION AND HISTORY
Tell Us about Your Child:
Today’s Date: ________________
Child’s Name_____________________________________ Child’s Age____________
Nickname____________________ Male_________ Female_________
Child’s Birth date________________
Social Security #______________________
Child’s Address__________________________________________ Apt. #___________
City _________________________________ State________ Zip code_____________
Child’s Home Phone # (
) __________________
Who Is Accompanying The Child Today?
Name_______________________________________ Relationship_________________
Do you have legal custody of this child? Yes____ No____
The Parent or Guardian who accompanies the Child is responsible for payment (not covered by insurance) at the time of service.
Mother’s Information:
Stepmother Yes____ or No _____
Name______________________________ Guardian? Yes______ No______
Home # (
) ________________________ Cell # (
) ______________________
Employer______________________________ Work # (
) ___________________
Address (Work) ________________________________________________________
City_______________________ State___________ Zip code____________________
Social Security#__________________________ DL# _________________________
Father’s Information:
Stepfather Yes ____ or No _____
Name_____________________________ Guardian? Yes_______ No_______
Home #_________________________ Cell# (
) ____________________________
Employer___________________________Work # (
) _______________________
Address (Work) ________________________________________________________
City________________________State__________________ Zip code_____________
Social Security #__________________________ DL#_________________________
Email Address: ______________________________________
Marital Status: (Circle One) Single/ Married/ Separated/ Widowed/ Divorced
REFERRAL SOURCE
Whom may we thank for this referral?
Physician Name ________________________________ Phone# ( ) ____________________________
Insurance Net Work _____________________________ Friend or Family (Name) ___________________
Advertisement _________________________________ Other ___________________________________
Dynamic Pediatric Dentistry For Children, PLC
Cindy Wilson, DDS
Tel# 772-221-3112 Fax# 772-221-3175
PLEASE BRING YOUR INSURANCE CARD TO THE APPOINTMENT
DENTAL INSURANCE INFORMATION
Eligibility date: _________________
Policy Owner’s Name: _______________________________
Relationship to Patient: _______________________________
Policy Owner’s Date of Birth: __________________________
Policy Owner’s Address: _______________________________________________
City, State, Zip code: ______________________________________
Telephone #: Home (
) _______________ Cell ( ) _______________________
Social Security #: ____________________________
Patient (Child’s) Name: ________________________________________________
Other Sibling(s) that we treat: ___________________________________________
Policy Owner’s Employer: _____________________________________________
Address: _____________________________________
City, State, Zip code: ___________________________
Employer’s work phone # (
) ________________________
Insurance Company Name: ____________________________________________
Claim billing address: __________________________________________
City, State, Zip code: ___________________________
Telephone #: (
) __________________________
Fax #: (
) ________________________________
Policy/Group Number: ____________________________
ID Number: ______________________________
RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS
I understand that my contract for dental insurance coverage is between the insurance carrier and
me. I authorize and release of any medical/dental information necessary to process insurance
claims and coordinate care with other physicians involved in my child’s health care. I am also
aware that Dynamic Pediatric Dentistry For Children, PLC will bill my insurance carrier as a
courtesy. I agree to pay any balance not covered by my insurance at the time dental services are
provided. I agree that copies of this form will be valid as original. I hereby authorize payment
directly to the above named dentist for the dental insurance benefit, otherwise payable to me.
_____________________________________________
_____________________
Signature of Policy Owner/ Guardian
Date
Dynamic Pediatric Dentistry For Children, PLC
Cindy Wilson, DDS
Tel# 772-221-3112 Fax# 772-221-3175
DENTAL HISTORY
Is this your child’s first visit to the dentist? _______________________
Date of last visit to the dentist ______________________
Is this an emergency visit? _______________
If yes, please explain _________________________________________________
Does the child have any of the following habits? Y=YES N=NO
Y N Lip Sucking/ Biting
Y N Nail Biting
Y N Nursing Bottle Habits
Y N Thumb/ Finger Sucking
Y N Mouth Breathing, Pacifier, etc Y N Grinding/Clenching
Is the child taking fluoride supplements? Yes
No
Has the child ever had any pain or tenderness in his/her jaw/joint? Yes
No
Does the child brush his/her teeth daily? Yes
No
Floss his/her teeth daily? Yes
No
Do you assist your child with tooth brushing? Yes
No
HEALTH HISTORY
Has the child had any history of or difficulty of the following conditions?
Please check mark:
__Accidents or severe infections
__Convulsions, Seizures, or Epilepsy
__ Malignancies
__AIDS or AIDS related Symptoms, HIV+ __Mental Retardation
__Diabetes
__Anemia or blood disorders
__Speech, Learning Disorder
__Headaches
__Asthmas or lung problems
__Heart murmur, heart disease
__Hyperactivity
__Bleeding Problems
__Vision, hearing problems
__Other
__Blood transfusions
__Kidney or bladder problems
__Cerebral palsy
__Liver problems, jaundice or hepatitis
__Any hospital stays
__Handicaps/Disabilities
__Rheumatic/Scarlet Fever
__Allergies to Latex
__Allergies to Penicillin or other drugs
__Food Allergies
__Other Allergies
PLEASE DESCRIBE ANY CURRENT MEDICAL TREATMENT INCLUDING DRUGS, PENDING SURGERY,
RECENT INJURIES, OR OTHER INFORMATION THE DENTIST SHOULD BE AWARE OF THAT HAS NOT
BEEN COVERED ABOVE._____________________________________________
_____________________________________________________________________________________________
_______________________________________________________________________________
Consent
I understand that the information I have given is correct to the best of my knowledge, 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.
The undersigned hereby authorizes Cindy Wilson, DDS and the dental staff to perform the
necessary dental services my child may need.
Signature of Parent/Guardian__________________________Relationship:___________