New Patient Forms Please enable JavaScript in your browser to complete this form.Patient's First Name *Patient's Last Name *Date of Birth *Sex *AgeAddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipIf Patient Attends School Please Tell Us Where They Go?CityUS States TexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICWhom May We Thank For Referring You?Parent/Guardian Full NameDate of BirthAddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipRelationship To PatientCell/Home PhoneWork PhoneEmail *Social Security NumberEmployerDo You Have Any Other Children?Name of Policy HolderDate of Birth of Policy HolderInsurance CompanyInsurance AddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipPhoneGroup NumberSubscriber IDSocial Security NumberRelationship To PatientName of Policy HolderDate of BirthInsurance CompanyInsurance AddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipInsurance Phone NumberGroup NumberSocial Security NumberSubscriber IDRelationship To PatientIs Your Child Under The Care Of A Physician?YesNoIf Yes, Physician Office NameIf Yes, Physician NamePhysician Phone NumberDate Of Last Physical ExamHas Your Child Been Hospitalized In The Last 5 Years?YesNoIf Yes, Please Explain;Is Your Taking Any Medications? Including Over The Counter and Prescriptions *YesNoPlease List All MedicationsFor Female Patients - Is The Patient Pregnant?YesNoFor Female Patients - Is The Patient Nursing An Infant?YesNoFor Female Patients - Is The Patient on Birth Control?YesNoDoes Your Child Have Any Known Drug Allergies?YesNoIf Yes, Please List AllergiesHas Your Child Ever Had A Reaction To An Anesthetic?YesNoIf So, Please ExplainPlease Check If You Have The FollowingADD/ADHDAnemiaAsthmaAutismBleeds/Bruises EasilyBone/Joint ProblemCancerCleft Lip/PalateCongenital Birth DefectDevelopment DelayDiabetesEar Infection/RecurrentHearing/Visual ProblemsHeart AnomalyHypo/HyperthyroidImmune ComprimisedInfectious DiseaseKidney ProblemsNeurological DisorderRespiratory ProblemsSeizuresSickle Cell AnemiaSyndrome (i.e. Down)Other:Do Your Child's Gums Bleed While Brushing or Flossing?YesNoAre Your Child's Teeth Sensitive To Hot or Cold Liquids/Foods?YesNoDoes your child feel pain in any of his/her teeth?YesNoDoes your child have any sores or lumps in his/her mouth?YesNoHas your child ever suffered trauma to his/her face/mouth or jaw?YesNoDoes your child have any pain in his/her jaw joint, ear, or side of the face?YesNoDoes your child have difficulty opening or closing his/her mouth?YesNoDoes your child clench or grind their teeth?YesNoHow many times a day does your child brush his/her teeth OnceTwiceDoes your child use mouth rinse?YesNoHas your child had any traumatic dental experiences in the past?YesNoIf yes to any of the questions above, please explain:What Would You or Your Child Change About His/Her Smile?Single Checkbox FieldI certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false or incorrect information can be dangerous to my child's health.CommentSubmit
