child`s registration and history - Dynamic Pediatric Dentistry for
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:___________
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