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Child's Name:
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Nick Name:
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Age:
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DOB:
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Sex:
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Reason for Visit:
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Referred By:
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Best Number to call to confirm appointment:
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Email Address:
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Can we contact you by email?
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How often does your child brush?
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Is toothbrushing supervised?
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If Yes, By Whom?
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Is Dental Floss used?
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Does your child receive any of the following?
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Fluoride in vitamins
Fluoride in tablets/drops
Fluoridated water
Bottled water
Well water
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Is this your childs first dental visit?
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Previous dentist:
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Date of last cleaning:
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Date of last x-rays:
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Any injuries to your child's teeth or jaws?
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If yes, please explain and give dates:
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Does your child have a history of any of the following?:
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Breast feeding
Bottle habits
Thumb/finger sucking
Pacifier
Dental Grinding or clinching
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If Yes, please explain and give dates:
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Is there anything that would be calming to talk to your child about while in the dental office? Baseball, dance, soccer, etc...?:
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Has your child had any of the following medical conditions?:
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Asthma
Cancer
Congenital Heart Failure
Convulsion/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impaired
HIV/Aids
Tuberculosis
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Child's Physician:
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Physician's Number:
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Is your child allergic to any medications?
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If yes, please list the medications:
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Is your child taking any medications?:
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If yes, please list the medications being taken:
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Are there any medical problems you would like to let us know about at this time?
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Primary Dental Insurance:
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Group Number:
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Policy Holder's Name:
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Membership Number:
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Employer:
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DOB:
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Social Security Number:
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Father/Step Father/Legal Guardian Name:
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Work Number:
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Home Number:
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Cell Number:
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DOB:
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Social Security Number:
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Occupation:
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Street Address:
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City, State, ZIP:
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Mother/Step Mother/Legal Guardian Name:
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Work Number:
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Home Number:
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Cell Number:
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DOB:
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Social Security Number:
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Occupation:
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Street Address:
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City, State, ZIP:
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