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New Patient Enrollment
  1. Step 1 - Patient Information:

    We require this information to see your child in our office.
  2. First Name*
    Please let us know your child's name.
  3. Middle Initial
    Invalid Input
  4. Last Name*
    Please provide your Child's last name.
  5. Date of Birth*
    / / We require your child's birth date
  6. Your Email*
    Please let us know your email address.
  7. Patient Phone*
    Please provide a primary phone number for contact information. This may be the same as the Responsible party. Please provide it in both places.
  8. Address*
    Please provide the address that your child resides.
  9. City*
    The address will require City, State and Zip
  10. State*
    The address will require City, State and Zip
  11. Zip Code*
    The address will require City, State and Zip
  12. Sex*
    Please specify your child's gender
  1. Step 2 - Responsible Party:

    We require only one Responsible Party. Please use this area for the second parent, other guardian, or to provide information required for proper insurance billing.
  2. Relationship to Child*
    Invalid Input
  3. First Name*
    Please let us know your name.
  4. Middle Initial
    Invalid Input
  5. Last Name*
    Invalid Input
  6. Date of Birth*
    / / Invalid Input
  7. Home Phone
    Please provide the primary number for the patient's residence. This may be a mobile or land line.
  8. Mobile Phone
    Please provide a mobile phone.
  9. Address*
    Invalid Input
  10. City*
    Invalid Input
  11. State*
    Invalid Input
  12. Zip Code*
    Please provide a valid Zip Code
  13. Sex*
    Invalid Input
  14. Social Security Number*
    Invalid Input
  15. Insurance Information

    If you are a Policy Holder for this child, please provide the following information to ensure proper insurance billing. We only require the Name of Employer. The address is the Insurance Company's mailing address for claims processing.
  16. Please Select whether this is Primary or Secondary Insurance
    Please select one
  17. Employer
    Invalid Input
  18. Occupation
    Invalid Input
  19. Insurance Company
    Invalid Input
  20. Group Number
    Invalid Input
  21. Member ID
    Invalid Input
    This number is required for all insurance companies. This is sometimes the Policy Holder's Social Security Number.
  22. Mailing Address for Claims
    Invalid Input
    We do not require the employer address, we do need to have the mailing address for claims processing. This information is generally found on the back of the insurance card.
  23. City
    Invalid Input
  24. State
    Invalid Input
  25. Zip Code
    Please enter a valid Zip Code
  1. Step 3 - Additional Responsible Party:

    We only require one Responsible Party. However, the following information is helpful to list the other parent/guardian. Any additional Insurance Policy Holders would be listed here.
  2. Relationship to Child
    Invalid Input
  3. First Name
    Please let us know your name.
  4. Middle Initial
    Invalid Input
  5. Last Name
    Invalid Input
  6. Date of Birth
    / / Invalid Input
  7. Address
    Invalid Input
  8. City
    Invalid Input
  9. State
    Invalid Input
  10. Zip Code
    Please enter numbers only
  11. Sex
    Invalid Input
  12. Social Security Number
    Invalid Input
  13. Insurance Information

    If you are a Policy Holder for this child, please provide the following information to ensure proper insurance billing. We only require the Name of Employer. The address is the Insurance Company's mailing address for claims processing.
  14. Please Select whether this is Primary or Secondary Insurance
    Please select one
  15. Employer
    Invalid Input
  16. Occupation
    Invalid Input
  17. Insurance Company
    Invalid Input
  18. Group Number
    Invalid Input
  19. Member ID
    Invalid Input
    This number is required for all insurance companies. This is sometimes the Policy Holder's Social Security Number.
  20. Mailing Address for Claims Processing
    Invalid Input
  21. City
    Invalid Input
  22. State
    Invalid Input
  23. Zip Code
    Please enter a valid Zip Code
  1. Step 4 - Medical History:

    Your child's Medical History is important to our office and often contributes to your child's oral care. Although dental personnel primarily treat the area in and around your mouth. Your child's mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationships with the dentistry you will receive. Thank you for answering the following questions.

    Please mark a "YES" for any of the following items that contribute to your child's medical history. Any additional information may be entered in the text field below.

  2. Allergic to Metal*
    Please select Yes or No
  3. Allergic to Latex*
    Please select Yes or No
  4. Allergic to Sulfa Drugs*
    Please select Yes or No
  5. Allergic to Other (Please List Below)*
    Please select Yes or No
  6. Currently Under Physicians Care*
    Please select Yes or No
  7. Previous Hospitalizations*
    Please select Yes or No
  8. Previous Major Operation*
    Please select Yes or No
  9. Previous Head Injury*
    Please select Yes or No
  10. Previous Neck Injury*
    Please select Yes or No
  11. Previous Blood Tranfusion*
    Please select Yes or No
  12. Current or Previous Chemotherapy*
    Please select Yes or No
  13. Current or Previous Cold Sores*
    Please select Yes or No
  14. Current or Previous Fever Blisters*
    Please select Yes or No
  15. Current or Previous Fainting or Diziness*
    Please select Yes or No
  16. Previous or Current Kidney Problems*
    Please select Yes or No
  17. Previous or Current Liver Disease*
    Please select Yes or No
  18. Currently Taking Pills or Drugs*
    Please select Yes or No
  19. Currently on a Special Diet*
    Please select Yes or No
  20. Currently Use Tobacco*
    Please select Yes or No
  21. Diagnosed with ADHD/ADD*
    Please select Yes or No
  22. Diagnosed with Autism*
    Please select Yes or No
  23. Diagnosed with Anemia*
    Please select Yes or No
  24. Diagnosed with Asthma*
    Please select Yes or No
  25. Diagnosed with Blood Disease*
    Please select Yes or No
  26. Diagnosed with Cancer*
    Please select Yes or No
  27. Diagnosed with Diabetes*
    Please select Yes or No
  28. Diagnosed with Epilipsy*
    Please select Yes or No
  29. Diagnosed with Heart Murmur*
    Please select Yes or No
  30. Diagnosed with High Blood Pressure*
    Please select Yes or No
  31. Diagnosed with Low Blood Pressure*
    Please select Yes or No
  32. Breathing Problem*
    Please select Yes or No
  33. Experience Convulsions*
    Please select Yes or No
  34. Experience Seizures*
    Please select Yes or No
  35. Experience Excessive Bleeding*
    Please select Yes or No
  36. Frequent Cough*
    Please select Yes or No
  37. Hay Fever*
    Please select Yes or No
  38. Mitral Valve Prolapse*
    Please select Yes or No
  39. Psychiatric Care*
    Please select Yes or No
  40. Rheumatic Fever*
    Please select Yes or No
  41. Sickle Cell Disease*
    Please select Yes or No
  42. Sinus Trouble*
    Please select Yes or No
  43. Spina Bifida*
    Please select Yes or No
  44. Stroke*
    Please select Yes or No
  45. Swelling of Limbs*
    Please select Yes or No
  46. Thyroid Disease*
    Please select Yes or No
  47. Tonsilities*
    Please select Yes or No
  48. Tuberculosis*
    Please select Yes or No
  49. Tumors or Growths*
    Please select Yes or No
  50. Ulcers*
    Please select Yes or No
  51. Yellow Jaundice*
    Please select Yes or No
  52. My child has medical information, a handicap, or disability not listed above.*
    Please select Yes or No
  53. Explanation from Medical

    Please use this field to describe any illness checked above or to list additional medical history for your child.
  54. Invalid Input
  55. Medicines

    Please provide a list of any medicines your child is currently taking. Please include both prescription and over the counter medicines.
  56. Invalid Input
  57. Child's Physician

    Please provide us your child's physician's name and contact information.
  58. Physician's Name
    Please let us know your name.
  59. Physicians Address
    Please let us know your name.
  60. Physician's Phone
    Please enter a valid phone number
  61. How often does your child brush?
    Please specify a number.
  62. How often does your child floss?
    Please specify a number.
  63. Is your child's water fluoridated?
    Invalid Input
  64. Previous Dentist

    Please provide us your child's previous dentist name and contact information.
  65. Dentist Name
    Please let us know your name.
  66. Dentist Address
    Please let us know your name.
  67. Dentist Phone
    Please enter a valid phone number
  68. Please provide your last Dental Visit
    / / Invalid Input
  69. Authorization and Release

    By submitting this form, I attest that I am authorized to provide the requested information for the child listed. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform necessary dental services my child may need. I acknowledge the receipt of Health Insurance Portability and Accountability (HIPPA) Information. I authorize the dentist to release any information including the diagnosis and the records of treatment of examination rendered to my child during the period of such care to third-party payers and /or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dentist’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.