Raleigh Cosmetic & Family Dentistry by Morrison & Lloyd, DDS

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Child New Patient Form

	YOUR CHILD
Child's Name	Please enter a name.
Nickname	Please enter a nickname.
Sex	Invalid Input
Birthdate	Invalid Input
Age	Please enter a valid age.
SS#/SIN	Invalid Input
School	Invalid Input
Grade	Invalid Input
Child's Home Address	Invalid Input
City	Invalid Input
State	Invalid Input
Zip/P.C.	Invalid Input
Phone	Invalid Input
	RESPONSIBLE PARTY
Name	Invalid Input
Relationship	Invalid Input
Address	Invalid Input
City	Invalid Input
State	Invalid Input
Zip/P.C.	Invalid Input
Email	Please enter a valid email or check your email format.
SS#/SIN	Invalid Input
DL#	Invalid Input
	WHO IS RESPONSIBLE FOR MAKING APPOINTMENTS
Name	Invalid Input
Home Phone	Invalid Input
Work Phone	Invalid Input
CellPhone	Invalid Input
Best time to call	Invalid Input
Time	Invalid Input
	MOTHER
	StepmotherGuardian Invalid Input
Name	Invalid Input
Home Phone	Invalid Input
Cell Phone	Invalid Input
Work Phone	Invalid Input
Ext	Invalid Input
Email	Please enter a valid email address or check your email format.
Employer	Invalid Input
Occupation	Invalid Input
SS#/SIN	Invalid Input
DL#	Invalid Input
Marital Status	SingleMarriedDivorcedWidowedSeparated Invalid Input
	FATHER
	StepfatherGuardian Invalid Input
Name	Invalid Input
Home Phone	Invalid Input
Cell Phone	Invalid Input
Work Phone	Invalid Input
Ext	Invalid Input
Email	Please enter a valid email addres or check your email format.
Employer	Invalid Input
Occupation	Invalid Input
SS#/SIN	Invalid Input
DL#	Invalid Input
Marital Status	SingleMarriedDivorcedWidowedSeparated Invalid Input
	PRIMARY INSURANCE
Insured's Name	Invalid Input
Relationship	Invalid Input
Birthdate	Invalid Input
SS#/SIN	Invalid Input
Employer	Invalid Input
Date Employed	Invalid Input
Occupation	Invalid Input
Insurance Company	Invalid Input
Group #	Invalid Input
Employee #	Invalid Input
Ins. Co. Address	Invalid Input
City	Invalid Input
State/Prov.	Invalid Input
Zip/P.C.	Invalid Input
Deductible	Invalid Input
Copay	Invalid Input
Amount already used	Invalid Input
Max. Annual Benefit	Invalid Input
	ADDITIONAL INSURANCE
Name	Invalid Input
Relationship	Invalid Input
Birthdate	Invalid Input
SS#/SIN	Invalid Input
Employer	Invalid Input
Date Employed	Invalid Input
Occupation	Invalid Input
Insurance Company	Invalid Input
Group #	Invalid Input
Employee #	Invalid Input
Ins. Co. Address	Invalid Input
City	Invalid Input
State/Prov.	Invalid Input
Zip/P.C.	Invalid Input
Deductible	Invalid Input
Copay	Invalid Input
Amount already used	Invalid Input
Max. Annual Benefit	Invalid Input
	FINANCIAL ARRANGEMENTS
	For your convenience, we offer the following methods of payment. Please check the option which you prefer.
Payment in full at each appointment.	CashCheckVisaMasterCardI wish to discuss the office's payment policy Invalid Input
	DENTAL AND HEALTH HISTORY (CONFIDENTIAL)
	Your child's overall health as well as any medications which your child takes could have an important inter-relationship with the dental care your child receives. Please answer each of the following questions completely.
How often does your child brush?	Invalid Input
How often does your child floss?	Invalid Input
Is your child's water fluoridated?	YesNo Invalid Input
Does your child take fluoride supplements?	YesNo Invalid Input
	Does your child:
Suck thumb/finger	YesNo Invalid Input
Suck/Bite lip	YesNo Invalid Input
Bite/Chew nails?	YesNo Invalid Input
Chew hard objects (pencils, etc.)	YesNo Invalid Input
Grind teeth	YesNo Invalid Input
Clench Jaws	YesNo Invalid Input
Previous dentist	Invalid Input
Address	Invalid Input
Date of last dental visit?	Invalid Input
Has your child had difficulty with previous dental visits?	YesNo Invalid Input
Child's Physician	Invalid Input
Address	Invalid Input
Phone #	Invalid Input
Previous Hospitalizations/Surgeries/Serious Illness	Invalid Input
Is your child currently taking medications?	YesNo Invalid Input
If yes, please list	Invalid Input
Has your child ever taken Fen-Phen/Redux?	YesNo Invalid Input
Does your child have a history of allergies/sensitivities/adverse reactions to any drugs or medications (penicillin, Novocain, etc.)?	YesNo Invalid Input
If yes, please describe	Invalid Input
Does your child have a history of allergies to any other substances (lates, environmental, etc.)?	YesNo Invalid Input
If yes, please describe	Invalid Input
	Has your child ever had any of the following:
Asthma	YesNo Invalid Input
Cancer	YesNo Invalid Input
Hepatitis	YesNo Invalid Input
HIV/AIDS	YesNo Invalid Input
Hemophilia	YesNo Invalid Input
A persistent cough or throat clearing not associated with a known illness(lasting more than 3 weeks)	YesNo Invalid Input
Abnormal Bleeding	YesNo Invalid Input
Stomach, liver or kidney problems	YesNo Invalid Input
Handicaps/Disabilities	YesNo Invalid Input
Tuberculosis	YesNo Invalid Input
Diabetes	YesNo Invalid Input
Rheumatic Fever	YesNo Invalid Input
Congenital Heart Defect	YesNo Invalid Input
Heart Murmur	YesNo Invalid Input
Convulsion/Epilepsy	YesNo Invalid Input
Please explain any medical problems that your child has:
	AUTHORIZATION AND RELEASE
	To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services my child may need. I also authorize the Dentist to release any information including the diagnosis and records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the Dentist or Dentist's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of patient (or parent/guardian if minor)	Please enter patient's, parent's or guardian's name.
Date	Invalid Input
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Raleigh Cosmetic and Family Dentists

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