6 Child Welcome by T6Wo1568

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									                                Welcome To Our Practice
                                                Champaign Dental Care
                                                                                                               Date:
About Your Child
First Name                                                 M.I.                       Last Name
Nickname                                     Birth Date                                       Soc. Sec. #                -             -
Male  Female 
Street Address:                                                   City                         State           Zip
Home Phone                                       School                                                        Grade

Parent or Guardian Information
Mother’s Name                                                                                                   Step Mother 
Guardian
Street Address                                                            City                         State             Zip
Home Phone                                                Work Phone                                        Ext .
Mother’s Soc. Sec. #                -              -                Birth Date                          Drivers Lic. #
Employer                                Years Employed            Employers Address
Father’s Name                                                                                                    Step Father 
Guardian
Street Address                                                            City                         State             Zip
Home Phone                                                Work Phone                                        Ext .
Mother’s Soc. Sec. #                -              -                Birth Date                          Drivers Lic. #
Employer                                Years Employed            Employers Address

Primary Dental Insurance Information
IF NO INSURANCE COMPLETE FOR RESPONSIBLE PARTY
Insured’s Name                                                    Soc. Sec. #             -       -              Birth Date
Street Address                                                    City                         State           Zip
Home Phone                              Work Phone                        Cell Phone                            Relation
Employer                                Dental Ins. Co.                   Subscriber #                         Group #

Secondary Dental Insurance Information
Insured’s Name                                                    Soc. Sec. #             -       -              Birth Date
Street Address                                                    City                         State           Zip
Home Phone                              Work Phone                        Cell Phone                            Relation
Employer                                Dental Ins. Co.                   Subscriber #                         Group #

Method of Payment
 Payment in full at each appointment (cash or personal check)
 Payment in full at each appoint (VISA            MC       OTHER          ) Card #                                      Exp. Date
 I wish to discuss the Dental Office’s Financial Policy

Authorization
I hereby authorize payment directly to Paxton Dental Care of the group insurance benefits otherwise payable to me. I understand that I
am responsible for all costs of dental treatment. I hereby authorize Paxton Dental Care to administer such medications and perform
such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page is
correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about
my dental treatment to third party payors and/or other health professionals.
 Responsible Party Signature                                                       Date
Child’s Dental Information
Reason for today’s visit:      Exam and Cleaning      Emergency          Consultation
Please check any of the following problems that apply to the child:
 Loose tooth             Broken or Chipped tooth                       Sensitive tooth, teeth or gums                       Lost
or broken filling
 Stained teeth          Locking jaw                             Discomfort, clicking or popping in jaw            Teeth grinding
 Bad breath             Red, swollen or bleeding gums            Blisters or sores in/around mouth              Ringing in Ears
Please list any other symptoms the child may be experiencing



How many times a day does your child brush?                    How many times a week does your child floss?
Is the child’s drinking water fluoridated?                     How would you rate the child’s smile?
Does your child do any of the following?
 Thumb or finger sucking         Tongue thrusting or sucking  Lip sucking or biting          Heavy snoring  Mouth
breathing
Previous Dentist                                               Last Dental Exam                    Last X-rays

Whom may we thank for referring you to us?

Child’s Medical Information
Please check any of the following symptoms or conditions that your child has or has had in the past:
 Heart murmur           Rheumatic fever            Artificial heart valves       Congenital heart defect  Scarlet Fever
 Cancer                 Chemotherapy                Hearing problems             Tonsillitis                  Hepatitis
 Hemophilia             Birth Defects              Respiratory Problems          Leukemia/Anemia               ADHD
 Cleft Lip/Palate         Abnormal bleeding        Diabetes                      Hypoglycemia                  Asthma
 Cerebral Palsy           Difficulty breathing     High Blood Pressure           Low Blood Pressure        Downs Syndrome
 Autism                  Tuberculosis TB           Psychiatric Care              AIDS or HIV Infection  Liver Disease
 Kidney Disease         Thyroid Disease            Artificial Joints             Dizziness                    Fainting
 Allergies                  Seizures
Please List Any Heart Conditions:


Please check any of the following for allergies:
     Latex           Penicillin/Amoxicillin     Tetracycline          Erythromycin         Aspirin        Codeine        Iodine
     Sulfa          Dental Anesthetic         Percodan         Valium         Acrylic                Metals                Darvon
    Other:

Is your child currently under a physicians care?           Y        N        What for?


Please list any medications including non-prescription medication that your child is currently taking:


Please list any siblings your child may have and their age:


Please list any pets your child may have and their name:
What is your child’s favorite color?                           What is your child’s favorite book or toy?
What is your child’s favorite hobby?                           What is your child’s favorite movie?
The information on this page is correct to the best of my knowledge.
Parent or Guardian Signature                                                                       Date
Dr. Signature                                                  Date

								
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