New Patients

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PATIENT DETAILS

Child's Full Name *

First

Last

Child's Preferred Name (if different from first name)

Date of Birth *

anything for supplements,

Child's Sex *

PARENT/GUARDIAN INFORMATION

Parent/Guardian's Full Name *

First

Last

Relationship to Patient *

Primary Phone *

Email *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

MEDICAL HISTORY

Please let us know if your child has any of the following medical conditions. *

Heart condition
Asthma
Diabetes
Seizures/epilepsy
Bleeding disorder
Recent hospitalization/surgery
Allergies
None

Please check all that apply

Please list allergies. *

Are there any additional medical concerns we should know about? *

Is your child currently taking any medications? Please include inhalers, supplements, or ADHD medications.

Please indicate ALL medications AND supplements the child takes. Include dosage.

Has your child ever had any reactions or concerns with anesthesia or sedation?

Note any specific instances and reactions.

Does your child have developmental, behavioral, or sensory needs that would help us prepare for a safe visit (for example: autism, ADHD, anxiety, or sensory sensitivities)?

Please share anything you feel would help our team support your child.

Is your child under the care of a physician or specialist?

Physician or Specialist Name *

First

Last

DENTAL HISTORY

Has your child been to a dentist before? *

Has your child had cavities or dental treatment before? *

Has your child experienced dental pain recently? *

Please explain your child's dental pain.

Does your child experience dental anxiety? *

Has your child had any injury to their teeth or mouth? *

INSURANCE & CONSENT

Dental insurance or self-pay? *

Dental insurance
Self-pay

If you plan to use dental insurance, please bring your insurance card to your child’s appointment.

Insurance Provider

Emergency Contact Name *

Phone Number *

Relation to Patient *

ACKNOWLEDGMENT & CONSENT

Please review and confirm the following before submitting: *

I confirm the information provided is accurate.
I consent to routine dental examination and preventive care.
I consent to communication from the office via phone, text, or email.

Please select your preferred method of contact. *

Phone
Text
Email

Date *

Parent or Legal Guardian Name (Electronic Signature)

What to Bring to Your Appointment

Insurance & Payment Information

New Patient Form

PATIENT DETAILS

PARENT/GUARDIAN INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

INSURANCE & CONSENT

ACKNOWLEDGMENT & CONSENT

Questions?