Child New Patient Form

CHILD HEALTH HISTORY

Page 1
Child Medical History
Child Dental History

If you are human, leave this field blank.

Date *

Patient's Name *

(Goes By) *

Age

Address

Gender *

Date of Birth *

City

State

Zip

Phone

Family Email

Orthodontic Insurance Coverage?

Yes

Carrier Name / ID Number *

Secondary Insurance Coverage?

Yes

Carrier Name / ID Number *

Patient’s Dentist

Patient Referred By

School

Names/ages of sisters and/or brothers treated here

Father

Father’s Name

Date of Birth

Address

City

State

Zip

Phone

Business

Cell

Employer

Occupation

Parent’s Marital Status

Father's Dentist

Name

(Responsible party if different from above)

Address

City

State

Zip

Mother

Mother’s Name

Date of Birth

Address

City

State

Zip

Phone

Business

Cell

Employer

Occupation

Is either parent deceased?

Yes

Mother's Dentist

Name

(Nearest relative not living with you)

Address

City

State

Zip

Father

Mother

Office Location

SMYRNA

DUNWOODY

DULUTH