Southern Pediatric Dentistry P.A.
1515 N. Fant Street
Anderson, SC 29621
Office: 864-844-9393
Fax: 864-844-9395
www.southernpediatricdentistry.com
New Patient Information
(This record is confidential and for office use only. Thank you for completing this form in full.)
SOCIAL HISTORY
Patient’s Full Name:
Age:
Date of Birth:
Address:
(MM/DD/YYYY)
Child lives with: ☐ Both Parents
Siblings we treat:
Nickname:
(LAST, FIRST, MIDDLE)
Gender:
Patient SS Number:
________
City, St, Zip:
☐ Mother
☐ Father
☐ Grandparent
☐ Other
(NAME/ AGE)
Who is accompanying your child today?
(NAME/ RELATIONSHIP)
Do you have legal custody of this child? ☐ Yes
☐ No
Child’s Favorite Interests:
Whom may we thank for referring you (how did you hear about us)?
Referred by:
☐ Friend or family member
☐ General Dentist ☐ OB/GYN ☐ Pediatrician
(Please check all that apply and list below)
(NAME)
Emergency Contact (Other than parent)
Relationship
Emergency Contact: Home #
Cell #
PARENT/GUARDIAN INFORMATION
Mother’s Full Name:
Social Security #:
(LAST, FIRST, MIDDLE)
Address (if different from patient’s):
City, St, Zip:
Home Phone:
Email:
Cell Phone:
Driver’s License #:
Employer:
(COMPANY NAME)
Birthdate:
(OCCUPATION)
Father’s Full Name:
Work Phone:
Social Security #:
(LAST, FIRST, MIDDLE)
Address (if different from patient’s):
City, St, Zip:
Home Phone:
Email:
Cell Phone:
Driver’s License #:
Birthdate:
Employer:
Work Phone:
(COMPANY NAME)
(MM/DD/YYYY)
(MM/DD/YYYY)
(OCCUPATION)
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Southern Pediatric Dentistry P.A.
1515 N. Fant Street
Anderson, SC 29621
Office: 864-844-9393
Fax: 864-844-9395
www.southernpediatricdentistry.com
New Patient Information (Continued)
MEDICAL INFORMATION
Name of your child’s Pediatrician
Pediatrician’s Phone #
Has your child ever been diagnosed as having any of the following conditions?
☐ADD/ADHD
☐Epilepsy/ Convulsions
☐Hepatitis
☐AIDS/ HIV+
☐GERD/Acid Reflux
☐Kidney/ Liver Conditions
☐Asthma
☐Heart Disease/Murmur
☐Pregnancy
☐Cancer
☐Hemophilia/
☐Rheumatic/ Scarlet Fever
Blood
Disorders
☐Congenital Birth Defects
☐Tuberculosis
☐
Hearing
Impairment
☐Diabetes
☐Vision Impairment
Has the child had any serious medical conditions? Please specify (or write NONE)
Has the child ever had any surgery or operation? Please specify date and surgery (or write NONE)
Has the child ever had any hospital stay? Please specify (or write NONE)
Is the child currently taking any medications? Please specify (or write NONE)
Is the child allergic to any medications? Please specify (or write NONE)
Is the child allergic to Latex? ☐Yes ☐ No
DENTAL INFORMATION
Reason for bringing your child to the dentist
Is this your child’s first visit to the dentist? ☐Yes
☐ No
Previous Dentist’s Name
, Approximate date of last dental visit
What did child have done at that visit?
Have there been any injuries to the teeth, mouth, or face? ☐Yes
☐ No
If yes, please explain
Has your child ever had a serious or difficult problem associated with previous dental work?
☐Yes
☐ No If yes, please explain
Does the child brush his/her teeth daily? ☐Yes
☐ No
Does the child floss his/her teeth daily? ☐Yes
☐ No
Does the child have any of the following habits?
☐ Nursing/Bottle Sucking in Bed ☐ Thumb/Finger Sucking ☐ Nail Biting ☐ Lip Sucking
Page 2 of 3
Southern Pediatric Dentistry P.A.
1515 N. Fant Street
Anderson, SC 29621
Office: 864-844-9393
Fax: 864-844-9395
www.southernpediatricdentistry.com
New Patient Information (Continued)
PERMISSION TO PHOTOGRAPH
I grant Southern Pediatric Dentistry the right to take photographs of my child.
I authorize Southern Pediatric Dentistry to use and publish the photo in print and/or electronically.
Parent/ Legal Guardian Signature:
PAYMENT INFORMATION
Person Responsible for Account:
Billing Street Address:
Billing City, St, Zip:
Cell Phone:
Email:
(DATE)
(NAME)
(RELATIONSHIP)
Home Phone:
Work Phone:
PRIMARY DENTAL INSURANCE
Insurance Company Name:
Insurance Company Phone #:
Insurance Company Street Address:
City, St, Zip:
Insurance ID #:
Policy Owner’s Date of Birth:
Policy Owner’s Employer:
Policy Owner’s Name:
Policy Owner’s SS#:
Relationship to Patient:
SECONDARY DENTAL INSURANCE
Insurance Company Name:
Insurance Company Phone #:
Insurance Company Street Address:
City, St, Zip:
Insurance ID #:
Policy Owner’s Date of Birth:
Policy Owner’s Employer:
Policy Owner’s Name:
Policy Owner’s SS#:
Relationship to Patient:
I acknowledge that the above-mentioned information is correct to the best of my knowledge and
that it is my responsibility to inform this office of any changes in the child’s medical status. I
authorize Southern Pediatric Dentistry and staff to provide dental and related medical/surgical
treatment as necessary utilizing proper and acceptable methods to complete same, including
diagnostic radiographs and photographs.
Parent/ Legal Guardian Signature:
(DATE)
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