wightmanfamilydental.com - Child Registration Form Patient Information * Patient Name: (Required) Gender: Male Female Social Security Number: Birth Date: Age: Home Address: City: State: Zip: Primary Phone Number: Phone Type home cell OK to leave message? Yes No *E-mail: (Required) School: Grade: List any sports or extracurricular activities: Siblings (names and ages): Parent / Guardian Information Parent 1 Name: Marital Status Single Married Divorced Widowed Significant Other Relation to Child: Mother Step-Mother Guardian Other Social Security Number: Birth Date: Driver's License Number: Address (if different than child's): City: State: Zip: Primary Phone: Phone Type: home cell Secondary Phone: Phone Type: home cell Parent 2 Name: Marital Status Single Married Divorced Widowed Significant Other Relation to Child:: Father Step-Father Guardian Other Address (if different than child's): City: State: Zip: Primary Phone: Phone Type: home cell Secondary Phone: Phone Type: home cell Emergency Contact Information Emergency Contact's Name (other than parent): Phone Number: Relation to Child: Address: City: State: Zip: Person(s) you allow us to release appointment or medically-related information regarding your child to: Relation(s) to Child: Insurance Information Primary Insurance Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Co-pay (if known): Deductible (if known): Policy Holder's Name: Relation to Patient: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Secondary Insurance Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Co-pay (if known): Deductible (if known): Policy Holder's Name: Relation to Patient: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Dental History How did you hear about our practice? Ad Internet Family/Friend Physician Other Name of person referring (if applicable): Have we treated any other family members? Yes No Name: Have your child's tonsils or adenoids been removed? Yes No Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No Does your child have any missing or extra permanent teeth? Yes No Has your child ever had an injury to (select all that apply): Teeth Mouth Chin Does your child have speech problems? Yes No If so, explain: Does your child currently or has your child ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem Medical History Is your child currently being treated by a physician? Yes No Reason: Physician: Last Visit: Phone: Does your child have any allergies/sensitivities to medications or latex? Yes No If yes, please list: Is your child currently taking any prescription or over-the-counter medications? Yes No If yes, please list with the dosage: Has puberty and/or menstruation begun? Yes No NA Has your child had any serious illnesses or operations? If yes, describe: Has your child ever had a blood transfusion? Yes No If yes, give approximate dates: Check if your child has or has ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD) Authorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. Submitted by: Date:
