New Patient Form for Children Today's Date(Required) MM slash DD slash YYYY Child's Name(Required) First Last Nickname Male or Female?(Required)MaleFemaleChild's Birth Date(Required) MM slash DD slash YYYY Age Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Child's School(Required)Home #(Required)Cell #(Required)Email(Required) Whom may we thank for referring you? General Dentist(Required) Last Visit Date(Required) MM slash DD slash YYYY Orthodontic Coverage(Required)YesNoI don't knowInsurance Co. Name(Required) Insurance Co. Address Insurance Co. Phone NumberGroup # Insured's Name(Required) First Last Insured's Birth Date(Required) MM slash DD slash YYYY Insured's ID or SS # Insured's Employer Guardian 1 InformationName(Required) First Last Employer(Required) Occupation(Required) Birth Date(Required) MM slash DD slash YYYY Contact Number(Required)Primary Contact Email(Required) Guardian 2 InformationName First Last Employer Occupation Contact NumberPrimary Contact Email Child's Physician's Name(Required) Physician's Phone #(Required)Date of Last Visit(Required) MM slash DD slash YYYY Are you taking any prescription drugs?(Required)YesNoPlease List Are You Pregnant?(Required)YesNoAre You Nursing?(Required)First ChoiceSecond ChoiceThird ChoiceDo you have any known allergies?(Required) Has your child ever had or been evaluated for orthodontic treatment?(Required) Has your child ever had a serious/difficult problem associated with any previous dental work?(Required) Does your child now or have ever experienced pain in our jaw joint? (TMD)(Required) Has your child ever had an injury to your mouth/teeth/face?(Required) Does your child have any speech problems?(Required) Does your child clench or grind teeth?(Required) Does your child have any missing or extra permanent teeth that you know of?(Required) Anemia/Radiation Treatment(Required) Artifical Bones/Joints(Required) Artificial Valves(Required) Asthma/Arthritis(Required) Blood Transfusion(Required) Cancer/Chemotherapy(Required) Congenital Heart Defect(Required) Diabetes/Tuberculosis(Required) Difficult Breathing(Required) Drug/Alcohol Abuse(Required) Emphysema/Glaucoma(Required) Epilepsy/Seizures(Required) Fever Blisters/Herpes(Required) Heart Attack/Stroke(Required) Heart Murmur(Required) Heart Surgery/Pacemaker(Required) Hemophilia/Abnormal Bleeding(Required) Hepatitis(Required) High/Low Blood Pressure(Required) HIV/AIDS(Required) Hospitalizations(Required) Kidney Problems(Required) Mitral Valve Prolapse(Required) Psychiatric Problems(Required) Rheumatic/Scarlet Fever(Required) Severe/Frequent Headaches(Required) Shingles(Required) Sinus Problems(Required) Ulcers/Colitis(Required) Please list any serious medical conditions that you have ever had:(Required) SignatureUntitled Untitled
