Save Time at Your Visit With Our Digital Child Registration Form

Gender:(Required)
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Please enter a number from 1 to 150.
Previous / Present dentist(Required)
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Other family members seen by us?

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Did you visit our website?
Friend / Family member name
Does your child have any learning disabilities or special needs?(Required)

Who Is Responsible For Making Appointments?

May we send text messages to this cell phone?(Required)

Parent Information

Do you have legal custody of this child?(Required)
Marital Status:(Required)
Mother's Information:
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Father's Information:
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Person Responsible For Account

In The Event Of An Emergency, Who Should We Contact?

Dental Insurance Information

Primary Insurance

Orthodontic Coverage?
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Secondary Insurance

Orthodontic Coverage?
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Medical and Dental History

Has your child been to the dentist before?
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Are there any dental problems that you are aware of presently?
Does your child brush his / her teeth daily?
Please rate your child's oral health:
Please rate your child's mental health:
Is your child currently under the care of a physician?
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Is your child taking any prescription drugs?
Does your child need to be pre-medicated before dental treatment?
Is your water fluoridated?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMDJ)?
Has your child's adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Does your child have a history of any previous surgeries?

Are You Allergic To Any Of The Following?

Any metal:
Latex:
Aspirin:
Penicillin:
Codeine:
Plastic:
Dental Anesthetics:
Tetracycline:
Erythromycin:
Other:

Did / Do your child have any of the following habits?

Tongue thrust:
Speech problems:
Nail biting:
Used pacifier?
Mouth breather:
Thumb / Finger sucking:
Clenching / Grinding teeth:
Nursing bottle habits:
Were you breastfed?

Have you ever had any of the following medical problems?

HIV + AIDS:
Anemia:
Any hospital stays:
Asthma:
Cancer:
Chicken pox:
Diabetes:
HIV / AIDS:
Heart murmur:
Hemophilia:
Hepatitis:
Hives:
Kidney problems:
Liver problems:
Measles:
Mononucleosis:
Skin Rash:
Tuberculosis (TB):
Congenital heart defect:
Convulsions / Epilepsy:
Handicaps / Disabilities:
Hearing Impairment:
Abnormal bleeding:
Immunizations current:
Mitral valve prolapse:
Rheumatic / Scarlet Fever:
Any operations:
If yes, please explain
Any stays in hospital:
Are there any medical conditions or problems relating to your child that need further explanation?
(Required)
The parent or guardian who accompanies the child is responsible for payment at the time of service unless prior arrangements have been approved.(Required)
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