Download Safari Smiles Child Registration and Health History

saFaRi sMiLes Child Registration and Health History
Tell us about your child
Primary Dental Insurance
Today’s Date: ______/_______/___________
Child’s Name: ___________________________________________
Insurance Company Name:__________________________________
Insurance Company Address:________________________________
________________________________________________________
Insurance Co. Phone:________________________
Group # ____________________Policy #:______________________
Insured’s Name:__________________________________________
Relationship to Patient:____________________________________
Insured’s DOB: ______/______/________
Insured’s SSN:_______-_______-_____________
Insured’s Employer:_______________________________________
Employer Phone:_________________________________________
Orthodontic Coverage?
Yes No (circle one)
Last
First
MI
Preferred Name:__________________
Male or Female (circle one)
Child’s Age: ______ Child’s Date of Birth:____/_____/__________
School: ______________________________ Grade: __________
Child LIVES with: ________________________________________
Name
_____________________________________________________________
Address
_____________________________________________________________
City
State
Zip
Who is accompanying your child TODAY?
_________________________________________________________________________________
Name
Relationship
Do you have legal custody of this child?
Yes
No
How did you hear about us? (please select one)
 Mailer
 Billboard
 Phone Book
 Internet
Referral (whom can we thank?)_________________________________
Other (please list)_________________________________________
Mother’s Information: Biological
Stepmother
Legal Guardian
(Circle one of the above)
Name: ________________________________________________
Employer:______________________________________________
SSN: ______-____-________
DOB: ____/_____/_________
Home Phone: _________________ Cell Phone:______________
Work Phone: __________________ (Circle best number for reminder calls)
Email:______________________________(Confidential! -reminder messages)
Father’s Information:
Biological
Stepfather
Legal Guardian
(Circle one of the above)
Name: ________________________________________________
Employer:______________________________________________
SSN: _________-_______-_____________
DOB: _______/_______/____________
Home Phone: _________________ Cell Phone:______________
Work Phone: __________________ (Circle best number for reminder calls)
Email:______________________________(Confidential! -reminder messages)
Person Responsible for Account (If different from above)
Name:________________________________________________
Relationship to Patient:__________________________________
Billing Address: _________________________________________
State
Insurance Company Name:__________________________________
Insurance Company Address:________________________________
________________________________________________________
Insurance Co. Phone:________________________
Group # ____________________Policy #:______________________
Insured’s Name:__________________________________________
Relationship to Patient:____________________________________
Insured’s DOB:______/______/________
Insured’s SSN:_______-_______-_____________
Insured’s Employer:_______________________________________
Employer Phone:_________________________________________
Orthodontic Coverage?
Yes No (circle one)
Other Adult Contacts
(These are used for reminder calls if primary phone numbers cannot be reached)
Name:_________________________________________________
Home Phone:________________ Cell Phone:_________________
Work Phone:_________________ (Circle best number)
Relationship to Patient:____________________________________
Name:_________________________________________________
Home Phone:________________ Cell Phone:_________________
Work Phone:_________________ (Circle best number)
Relationship to Patient:____________________________________
I understand that the information given is correct to the best
of my knowledge and that it will be held in the strictest of
confidence. It is my responsibility to inform this office of any
changes in my child’s address, dental insurance and/or
contact information.
______________________________________________________
Address
______________________________________________________
City
Secondary Dental Insurance
Zip
Contact Phone:________________________
Employer:______________________________________________
SSN:________-________-_____________
Signature of parent or guardian
Date
saFaRi sMiLes Child Registration and Health History
Medical History
Circle One
Is your child currently being treated by a physician?
Y or N
If yes, explain:_____________________________
Name of Physician__________________________
Is your child receiving any medications?
Y or N
(List current medications in box to right)
Is your child allergic to any medications?
Y or N
(List allergies to medication in box to right)
Does your child have other allergies?
Y or N
(List other allergies in box to right)
Has your child had any serious illnesses?
Y or N
(List serious illnesses in box to right)
Has your child ever had surgery or been hospitalized? Y or N
If yes, explain:_______________________________
Any complications? __________________________
Has your child had any history of any of the following?
Heart trouble, Murmur, or Heart Surgery?
Y
-Have you been instructed to take a premed by your Physician? Y
Asthma, TB, or other Breathing Issues?
Y
ADD/ADHD
Y
Bleeding Disorders?
Y
Latex or Rubber Allergies
Y
Cerebral Palsy or Developmental Delays?
Y
Speech or Hearing Problems?
Y
Emotional or Psychological Issues?
Y
Congenital Birth Defects?
Y
Cleft Lip and/or Palate?
Y
Syndrome or Genetic Disturbance?
Y
Epilepsy, Seizure Disorder, Fainting?
Y
Rheumatic or Scarlet Fever?
Y
Sickle Cell Anemia or Blood Disorder?
Y
Thyroid or other Glandular Issue?
Y
Kidney Infection?
Y
Diabetes?
Y
Cancer, Tumor, or Leukemia?
Y
HIV Infection or AIDS?
Y
Malignant Hypothermia? (or family history of this)
Y
Other Medical Conditions Not Listed Above?
Y
(List if Yes)_________________________________
Is the Patient or Parent Currently Pregnant?
Y
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
or
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
or
N
Current Medications: ____________________________________
____________________________________
____________________________________
Drug Allergies:__________________________________________
Other Allergies:_________________________________________
Serious Illnesses:________________________________________
______________________________________________________
Dental History
When and where was your child’s last dental visit?______________
_______________________________________________________
Were any x-rays taken?
Y or N
Did your child have difficulty cooperating?
Y or N
When does your child get his/her teeth brushed?
____ Morning ____ After eating ____ Before Bed
Does your child get assistance/supervision?
Y or N
Has your child had any cavities in the past?
Y or N
Have either parents had problems with cavities?
Y or N
Have there been any injuries to your child’s teeth?
Y or N
Do you expect your child to cooperate?
Y or N
Consent
I understand that the above information is correct to the best of my
knowledge, and that it will be held in the strictest of confidence. Because
my child is a minor, it is necessary that signed permission be obtained
from a parent or guardian before any dental services can be rendered. I
give my consent to Dr. Lindblom, his associates, and his dental team to
perform such treatment, services, medication, behavior management
techniques, local anesthesia and/or analgesia necessary to treat any
dental/oral deficiency, abnormality, and/or infection.
____________________________________________________________
Signature of Parent/Guardian
Relationship to Patient
Date
Office Use
Medical and Dental History Reviewed ______________________________________
Dentist Signature
Date
Office Use Only
________________________________________________________________________________________________________________________________________________________________________________
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