Peachtree Children’s Dentistry Nancy Kil, D.D.S. Demetris E. Rush, D.D.S. Pediatric Dentist Pediatric Dentist 3820 Pleasant Hill Road, Suite 1, Duluth, GA 30096 Phone (770) 497-0110 Fax (770) 497-0580 1905 Scenic Highway, Suite 510, Snellville, GA 30078 Phone (770) 979-6400 Fax (770) 979-7465 For your convenience… Print this form, complete all information, and bring it with you on your first visit to our office. The parent or Guardian who accompanies the child is responsible for payment at the time of service. Tell Us About Your Child Who is Accompanying the Child Today? Child’s Name ________________________________________ Last First Name _______________________________________________ MI Nickname______________________ Male Female Siblings that we treat __________________________________ Relationship__________________________________________ Do you have legal custody of this child? Yes No Child’s Birthdate _____/_____/_____ Child’s Age ___________ Child’s Home # (__________)___________________________ SS#________________________________________________ Child’s Home Address:_________________________________ Person Responsible for Account Name_______________________________________________ Relationship__________________________________________ Billing Address _______________________________________ ___________________________________________________ APT. / CONDO # ___________________________________________________ City State Zip ____________________________________________________ City State Zip Home # (____________)________________________________ Work # (____________)________________________________ E-mail ______________________________________________ Mother’s Information Primary Dental Insurance Name ______________________________________________ Stepmother Guardian Birthdate _____/_____/_____ Insurance Co. Name ___________________________________ Insurance Co. Address _________________________________ ____________________________________________________ Employer ___________________________________________ Insurance Co. Phone # (___________)_____________________ Work # (_________)____________________ Ext. __________ Group # (Plan, Local, or Policy #) _________________________ Home # (_________)__________________________________ Policy Owner’s Name __________________________________ Cellular Phone # (_________)___________________________ Relationship to Patient__________________________________ Policy Owner’s Birthdate ______/ ______/ ______ SS # _____________________ DL# _____________________ Social Security # ______________________________________ Policy Owner’s Employer _______________________________ Father’s Information Secondary Dental Insurance Name ______________________________________________ Stepfather Guardian Birthdate _____/_____/_____ Insurance Co. Name ___________________________________ Insurance Co. Address _________________________________ ____________________________________________________ Employer ___________________________________________ Insurance Co. Phone # (___________)_____________________ Work # (_________)____________________ Ext. __________ Group # (Plan, Local, or Policy #) _________________________ Home # (_________)__________________________________ Policy Owner’s Name __________________________________ Cellular Phone # (_________)___________________________ Relationship to Patient__________________________________ Policy Owner’s Birthdate ______/ ______/ ______ SS # _____________________ DL# _____________________ Marital Status Single Married Widowed Separated Divorced Social Security # ______________________________________ Policy Owner’s Employer _______________________________ Dental History Health History Is this your child's first visit to the dentist? _________________ Has the child ever had any of the following conditions? If not, how long since the last visit to the dentist? ____________ Y N Abnormal Bleeding Y N Handicaps/Disabilities Were any x-rays taken at previous dental visits? ____________ Y N Allergies to any Drugs Y N Hearing Impairment Y N Any Hospital Stays Y N Heart Murmur Y N Any Operations Y N Hemophilia Y N Asthma Y N Hepatitis Y N Cancer Y N HIV + / AIDS Have there been any injuries to the teeth, face or mouth? _____ ___________________________________________________ If yes, please explain __________________________________ ___________________________________________________ Y N Congenital Heart Disease Y N Kidney/Liver Conditions ___________________________________________________ Y N Convulsions/Epilepsy Y N Rheumatic/Scarlet Fever Why did you bring the child to the dentist today? ____________ Y N Pregnancy Y N Allergies to Latex Product ___________________________________________________ Please discuss any serious medical conditions the child has had ___________________________________________________ _____________________________________________________ Does the child have any of the following habits? _____________________________________________________ Y N Lip Sucking / Biting Y N Nail Biting Please list all drugs the child is currently taking _______________ Y N Nursing Bottle Habits Y N Thumb / Finger Sucking _____________________________________________________ Has the child ever had a serious or difficult problem associated Please list all drugs the child is allergic to ____________________ with previous dental work? _____________________________________________________ Yes No If yes, please explain __________________________________ Child's Physician _______________________________________ ___________________________________________________ Phone (_____________)_________________________________ Is the child’s water fluoridated? Is the child currently under the care of a physician? Yes No Is the child taking fluoride supplements? Yes No Yes No Does the child brush his/her teeth daily? Yes No Floss his / her teeth daily? No Yes No Please describe the child's current physical health... Good Has the child ever had any pain or tenderness in his/her jaw/ joint? (TMJ/TMD)? Yes Fair Poor Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA the CDC, and the ADA. Who may we thank for referring you to our office? _____________ _____________________________________________________ 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. I authorize the dental staff to perform the necessary dental services my child may need. _______________________________________________ Signature of Parent or Guardian Date _______________________________________ Relationship to Patient I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein. Doctor’s Comments ________________________________________ ________________________________________________________ Initials _____________ Date _______________ Insurance Verification: ________________________________________________________ Effective Date ______/______/_______ Preventive _________% Deductible $_________ ________________________________________________________ Basic _____________% Maximum $_________ Does insurance cover sealants (1351)? Major _____________% Electronic Claims Yes No Yes No If yes, what do they fall under? _______________________________