Let’s Get to Know Your Child

Today’s Date: _________________________________________

Child’s Name: _________________________________________

Birthdate: ____/____/_______ Male Female

Preferred Name: _______________________________________

Home Phone Number: _________________________________

Address: _____________________________________________

City______________________ State______ Zip code_________

Last Dental Visit: _____/_____/______ Where?_______________

Who is Accompanying this Child?Name: ___________________________________________

Relationship to Patient: _____________________________

Preferred method of contact: Phone Email Text Cell

How did you hear about us?___ Referred by Doctor___ Referred by Family/Friend Who can we thank for referring you?___ Web___Other: ________________________________________

Parent InformationMother’s Name: ____________________________________

Other Guardian: ___________________________________

Birthdate: ____/____/_______ Home#______________

Work#___________________ Cell#________________

SSN: _____________________________________________

Occupation: _______________________________________

Email: ____________________________________________

Parents’ Marital Status: Divorced Single Married

Father’s Name: ____________________________________

Other Guardian: ___________________________________

Birthdate: ____/____/_______ Home#______________

Work#___________________ Cell#________________

SSN: _____________________________________________

Occupation: _______________________________________

Email: ____________________________________________

Divorced Married Single

Primary Dental InsurancePolicy Owner’s Name: _________________________________

Policy Owner’s Birthdate: _____/ ______/ ___________

Insurance Company Name: ____________________________

Policy Owner’s Employer: _____________________________

ID #: ______________________________________________

Group #: ___________________________________________

Insurance Company Phone#: __________________________

Policy Owner’s Name: _________________________________

Policy Owner’s Birthdate: _____/ ______/ ___________

Insurance Company Name: ____________________________

Policy Owner’s Employer: _____________________________

ID #: ______________________________________________

Group #: ___________________________________________

Insurance Company Phone#: __________________________

Secondary Dental Insurance

I certify that my child is covered by the above insurance company and I assign directly to Woodlands Pediatric Dentistry all insurance bene�ts otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of bene�t. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

_______________________________________________________________________ _____________________________ Signature of Parent/Guardian Date

_____________

30014 Aldine West�eld Road, Suite 101Spring, TX 77386

Ph: (281) 393-4044

4850 West Panther Creek Drive, Suite 102The Woodlands, TX 77381Ph: (281) 292-4242

Woodlands Pediatric DentistryScott A. Andersen, DDS

Tab R. Imdacha, DDS, MSD

Health HistoryChild’s Physician: ______________________________________ Phone#:__________________________________________

Date of last visit: ______________________________________

Please describe your child’s current physical health: Good Fair Poor

Are your child’s immunizations up to date? Yes No

Please list all medications with dosage your child is currently taking: ________________________________________________________________

_________________________________________________________________________________________________________________________

Aside from the items listed below, please list anything your child is allergic to, including medication: ______________________________________

_________________________________________________________________________________________________________________________

Latex: Yes No Metals/Nickel: Yes No Plastic: Yes No

Has your child ever had any of the following medical issues?

Yes No Abnormal Bleeding Yes No Congenital Heart Defect Yes No HIV/AIDS

Yes No ADD/ADHD Yes No Convulsions Yes No Kidney/Liver Problems

Yes No Anemia Yes No Diabetes Yes No Measles

Yes No Any Hospital Stays Yes No Epilepsy Yes No Mononucleosis

Yes No Any Operations Yes No Exposed to HIV, but Neg Yes No Sensory Issues

Yes No Asthma Yes No Headaches Yes No Sickle Cell Disease/Traits

Yes No Autism/Asperger’s/PDD Yes No Hemophilia Yes No Skin Rash

Yes No Cancer Yes No Hepatitis Yes No Tuberculosis (TB)

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest con�dence and it is my responsibility to inform this o�ce of any changes in your child’s medical status. I authorize the dental sta� to perform the necessary dental services my child may need.

____________________________________________________________________ _____________________________________

Parent/Guardian Signature Date

Patient’s First Name: __________________ Last Name: _____________________ Birthdate: _____/ _____/ ________

Other: __________________________________________________________

Has your child had any history of:Thumbsucking:Fingersucking:

Prolonged breast or bottle feeding:Paci�er past age 2:

Bed Wetting:Snoring:

Pain/Tenderness jaw joint (TMJ / TMD):Does your child brush his/her teeth daily:

YES NO CURRENT

Chief purpose of this dental visit_________________________________________________________________Is your child in pain now? ______________________________________________________________________Has your child had any previous dental treatment?__________________________________________________Has your child had any unfavorable dental/medical experience?_________If yes, please explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________