Today’s date: ____________
ABOUT YOUR CHILD
Child’s name: ______________________________________
Home phone: ______________________________________
Address:___________________________________________
City:___________________ State:______ Zip:___________
School: ____________________________________________
Birth date: _____/_____/_____
Age:__________________
_ Female
_ Male
What is your child’s favorite sport? ______________________________________
Favorite toy? _______________________________Favorite hobby? ______________________________
Who can we thank for referring you? ____________________________________
Father’s name: ________________________________________________________
Cell phone: __________________________________________________________
Mother’s name:_______________________________________________________
Cell phone: __________________________________________________________
DENTAL INSURANCE INFORMATION(Primary Dental Insurance)
Name of policy holder: _____________________________________________Relationship:___________
Policy holder’s ID/social security #: ______________________________________
Group #: ________________________________________Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ______________________________________________
DENTAL INSURANCE INFORMATION(Secondary Dental Insurance)
Name of policy holder: _____________________________________________Relationship___________
Policy holder’s ID/social security #: ______________________________________
Group #: _______________________________________Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ______________________________________________
*I agree to be responsible for all charges for dental services and materials not paid by
my dental benefit plan, unless the treating dentist has a contractual agreement with
my plan prohibiting all or a portion of such charges, to the extent permitted under
applicable law. I authorize release of information relating to this claim. I also
authorize payment of dental benefits, otherwise payable to me, to be paid directly
to Brass City Dentistry L.L.C. Guardian’s Initials:_________
APPOINTMENT CANCELLATION POLICY
When you schedule an appointment, we reserve that time and prepare in anticipation of
serving you. If you should need to reschedule, we kindly request that you contact us by
phone with advanced notice of two (2) business days. We understand that conflicts arise;
however failing your appointment or canceling without adequate notice more than once
will result in a $50 charge and then discontinuation of services. Guardian’s Initials:_________
Child
History Form
DENTAL HISTORY
Is this your child’s first dental experience?
_ Yes
_ No
What is his/her attitude toward this visit?
______________________________________________________________________
How has he/she responded to past visits to the physician and/or dentist?
_ Very well
_ Moderately well
_ Moderately poor
_ Very poorly
How would you rate your own anxiety (fear, nervousness) at this moment?
_ High
_ Moderately high
_ Moderately low
_ Low
Does your child think there is anything wrong with his or her teeth, such as a chipped tooth, decayed
tooth, gumboil, etc.?
_ Yes _ No If yes, please explain:
________________________________________________________________________
How do you expect your child to behave in the dental chair? _ Very well _ Moderately well
_ Moderately poor
_ Very poorly
How much and how often does your child drink juices or soda pop?
__________________________________________________
Does/did your child suck their thumb? _ Yes _ No
If so, how often? _________________________________________________________________________
Does/did your child use a pacifier? _ Yes _ No
If so, how often? __________________________________________________________________________
MEDICAL HISTORY
Is your child in good health? _ Yes
_ No
Child’s physician: ________________________________________________Ph#_____________________
When was your child’s last medical exam? ___________________________________________________
Has your child required hospitalization or had a serious illness? _ Yes
_ No
If yes, please explain:
_________________________________________________________________________________________
__________________________________________________________________________________________
Are your child’s immunizations up-to-date? _ Yes
_ No
Is your child sensitive/allergic to anything? _ Yes
_ No
If yes, please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
Is your child presently taking any medications? _ Yes
_ No
If yes, please explain:
_________________________________________________________________________________________
Please check any of the following that apply to you:
_ Rheumatic fever
_ Asthma
_ Diabetes
_ Counseling
_ Heart murmur
_ Hay fever _ Breathing disorders _ Mitral valve prolapse
_ Epilepsy
_ Anemia
_ Hearing impairment
_ Visual impairment
_ Attention disorder
_ Other ___________________________________________________________
Guardian’s Signature __________________________________________
Date:_____________