Patient Information
Child’s Full Name:
_________________________________
Age:
Birthday:
________
Child’s Home Address:
Name called By: _____________________
__________________
_________________________________
_________________________________
____________ _______ _________
City
State
Zip
Sex:
 Male  Female
Phone: ____________________________
Alternate Phone: ____________________
Child’s Favorite Hobbies/Interests:
_________________________________________________________
Name of School/Daycare:
_________________________________________________________
Brother(s) (Name(s) & Ages):
_________________________________________________________
Sister(s) (Name(s) & Ages):
_________________________________________________________
Child’s Physician:
_________________________________
Phone Number: ______________________
Date of Last Exam:
_____________ Current Weight: _____________ Current Height: _______________
Parent/Guardian Information
Parent/Guardian Name: _______________________________
Social Security Number: _______________________________
Employer:
______________________________________
Relationship to Patient: _______________
Date of Birth: ________________________
Work Phone #: _______________________
Email Address: ________________________________________________________________________
How did you find out about our office? ____________________________________________________
Emergency Contact/Friend or Relative Not Living with You:
Name: ___________________________
Relationship: __________
Phone #: ___________
Insurance Information
Do You have North Carolina Medicaid or Health Choice?:
 Yes or
 No
If No:
Insured’s Name: ________________________________
Insured’s Date of Birth: _________________________
Name of Insurance Company: ______________________
Relationship to Patient:
Insured’s Employer:
ID #: _______________
_____________________
_____________________
Group #: _____________
I agree to be responsible for all charges for dental services and materials not paid by dental plan, unless Kidz Dental
Central has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by
law, I authorize the release of any information relating to claims filed. I hereby authorize payment of the dental benefits
otherwise payable to me to be paid directly to Kidz Dental Central.
Signature of Responsible Party: _____________________________________ Date:
_____________________
Medical History
Does your child currently have/previously had any of the following health problems?
 Yes  No
 Yes  No
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 No
 Yes  No
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
Allergies (Food, Drug, Dust, Additional)
If Yes, please list:
_______________________________
_______________________________
Rheumatic Fever/Rheumatic Heart Disease
If Yes, Is Pre-Med Needed?  Yes  No
Name of Pharmacy: __________________
Pharmacy Phone #: __________________
Diabetes/Blood Sugar Problems
Convulsions, Seizures, Fainting, or Epilepsy
Anemia
Asthma or Hay Fever
Are your child’s immunizations current?
Speech, Learning, or hearing disorders
 No
 No
 No
 No
 No
 No
 No
 No
 No
 No
 No
 No
High/Low Blood Pressure
Any Current/Recent Injuries
Childhood Illnesses
Blood Tranfusion
Bruise Easily
Bleeding Disorder
Kidney or Bladder Problems
Tuberculosis or Pneumonia
Liver Problems, Hepatitis
Accidents or Severe Infections
Psychological or Emotional Problems
Surgeries:
If yes: _________________________
Is your child currently taking any medications?
If Yes, Please list:
_____________________________________________________________________________
Please explain any other medical concerns: ____________________________________________________________________________
Dental History
Date of Last Dental Exam: _____________________________
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 No
 No
Which Office? __________________________
Do you have any current records (including x-rays) from another practice?
Has your child complained about any dental problems?
If Yes, Describe: _______________________________
Any injuries or surgeries to the mouth, teeth, or head?
If Yes, Describe: _______________________________
Does your child still take the bottle or Sippy cup?
Does your child brush daily?
How Often?
_______________________________
Is dental floss used?
Do you assist your child with brushing?
Please check if your child has any of the following habits:
 Thumb Sucking
 Pacifier
 Nail Biting
How does your child receive fluoride?

Water Supply
 Dentist
 Toothpaste
 Finger Sucking
 Grinding
 Tablets
 Other: ___________________________________
Child’s attitude towards dentistry: _______________________________________________________________________________________
Reason for visit today/chief complaint: ____________________________________________________________________________________
I hereby certify that all of the above information is correct and true. If the above named child is a minor, it is necessary
that a signed permission form is obtained from a parent or guardian before any and/or all necessary dental treatment
can be commenced. Furthermore, I authorize Kidz Dental Central to provide dental treatment for my child.
Signature of Responsible Party: _____________________________________ Date:
_____________________
Anesthesia Consent
Local Anesthesia (Tickle Juice)
I understand that local anesthesia may be used during the dental treatment. I understand that there are risks
involved with anesthesia. These risks include but are not limited too; dizziness, nausea, vomiting, accelerated
heart rate, slow heart rate, and allergic reaction.
Nitrous Oxide (Laughing Gas)
I understand that nitrous oxide and oxygen may be used during dental treatment. Nitrous oxide is perhaps the
safest sedative in dentistry. It also carries risks. These risks include but are not limited too; dizziness, nausea,
vomiting, accelerated heart rate, slow heart rate, and allergic reaction.
Please ask the staff if your have any questions regarding this consent form.
I hereby acknowledge that I have read this consent regarding anesthesia.
Signature of Responsible Party: _____________________________________ Date:
_____________________
Authorization for Release of Information
Kidz Dental Central is authorized to release protected health information about the patient to the entities listed
below. The purpose is to inform the patient or others in keeping up with the patient’s dental health.
Release of information is allowed to the parties below: (check all that apply)
Voicemail
 Yes  No
Spouse
 Yes  No
Provide Name: ___________________________________________________________
Other Family Member(s)  Yes  No
Provide Name(s): _________________________________________________________
The patient/responsible party has the right to revoke this authorization at any time with written notice to the
provider.
Signature of Responsible Party: _____________________________________ Date:
_____________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received a copy of the Notice of Privacy Practices for Kidz Dental Central.
(Please see Front Desk for a Copy if you would like one)
Signature of Responsible Party: _____________________________________ Date:
_____________________