New Patient Information

*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection (AES Encryption) and are HIPAA compliant.
Child Registration Form - Dental
* required field

Patient Information

 

 

Relationship

 


Insurance Information






 


 

Secondary Insurance






 


 

Emergency Contact





Person(s) OK to release appointment or medically related information to concerning patient.






 


 

Dental History


 

How did you hear about our Practice? *

 

Has patient's tonsils or adenoids been removed? *
Has patient ever experienced jaw joint pain/discomfort (TMJ/TMD)? *
Has patient ever had an injury to (select all that apply):
Does patient have speech problems? *
Does patient currently or has your child ever had any of the following habits?

Medical History

Is patient currently being treated by a physician? *

Does patient have any allergies/sensitivities to medications or latex? *

 

Is patient currently taking any prescription or over-the-counter medications? *

 

 

Has puberty and/or menstruation begun?

 

Has patient had any serious illnesses or operations? If yes, describe:
Has patient ever had a blood transfusion? *





 

Check if patient has or have ever had any of the following:

 

 

Unexpected weight loss, night sweats, recent travel outside US, bloody sputum, living close quarters or with a Tuberculosis patient?

 

 

Patient ever taken any of the following bone medications?

 


 

Does patient exhibit any of the following?

 

 

Has patient been evaluated for orthodontic treatment before?

 

 

How do you feel about braces?

 

 

What would patient like to change about their smile?

 

 

Any questions for Dr. Chenin?

 

 

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.


 



Security Measure
*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection (AES Encryption) and are HIPAA compliant.