Childs’ name:  ______________________________________  Date of Birth                                          .

Medical History  (circle all that your child has had or now has)                        Gender:        F  /  M        

ALLERGIES                CANCER                             HEARING IMPAIRMENT    LATEX ALLERGY       TB

ANEMIA                     CEREBRAL PALSY             HEART CONDITION           LIMITED MOTION      TUMOR

ASTHMA                    CLEFT LIP/PALATE             HEART MURMUR              LIVER DISEASE         TRAUMA

AUTISM                     DIABETES                           HEMOPHILIA                      MENTAL/PSYCHIATRIC
BLEEDING                 EPILEPSY                           HEPATITIS                          SEIZURES       
BLOOD CONDITION           HIV                             KIDNEY DISEASE              VISION IMPAIRMENT

Please List ANY allergic or unfavorable reaction to any medication or other

Does your child have any condition not listed above?________________________________________

Is your child taking any medications at this time?  Please list. _________________________________

Has your child ever had any serious illness, operation, or been hospitalized?______________________


Is there a family history of problems with general anesthetic?__________________________________

Who is your child’s physician?___________________________ Last physical exam?_______________

To the best of of my knowledge, the above information is correct.  I will inform the office of any change in my
child’s health at each visit.______________________________date:________________

Dental History                                        Referred By:                                                                                              

Family Dentist______________________________Is this your child’s first dental visit?  Yes / No

If not, last dental visit?_______________________Previous unfavorable experiences?  Yes / No

Recent toothache? Yes / No.              Previous Dental Trauma?  Yes / No      Habits?  Thumb/finger/ Other

Mother/Guardian_____________________________Relationship____________Date of Birth:_________
Marital Status:  (circle one)        Single        Married        Divorced        Email__________________________

Address_______________________________City, State__________________________Zip_________

Home Phone_____________________Work Phone__________________Cell_____________________

Employment______________________Work Address________________________________________

Occupation___________________________________Social Security #__________________________

Father/Guardian__________________________Relationship________Date of Birth:_________________

Marital Status: (circle one)        Single        Married        Divorced        Email__________________________

Address_______________________________City, State____________________Zip_______________

Home Phone_________________Work Phone________________Cell___________________________

Employment______________________Work Address________________________________________

Occupation_____________________________________Social Security #________________________

Nearest Relative not living with you: Name___________________________ ___Phone #______________

Insurance/Personal Payment Plans (please bring your card to the appointment)

Responsible  Party(print)_____________________________Sign_______________________________

Please circle:                  Cash  /  Charge Card  /  Insurance  /  Medicaid  /  Other

Primary Insurance__________________________Employee/Subscriber________________________

Group #______________________ Subscriber ID #_____________________Group________________

Insurance Company Address:______________________________________Phone________________

Secondary Insurance_________________________Employee/Subscriber________________________

Group #______________________ Subscriber ID #_____________________Group________________

Insurance Company Address:______________________________________Phone________________

I understand that responsibility for payment for Dental Services provided in this office for my dependents is mine and
that payment is due when services are rendered.  This office will help prepare the patient’s insurance forms and assist
in making collections through insurance companies, crediting such collections to the patient’s account.  However, this
practice cannot render service on the assumption that our charges will be paid by an insurance company.  Unless
financial arrangements are made, past due accounts incur finance charges of 1 ½% per month after 60 days and may
be submitted for collections in the event of default.
Signed____________________________________________(responsible party)Date____________
2300 W Everest Lane                                                                                Suite 125                                    
                                      MERIDIAN, ID  83646