GHPD Patient Registration Form

Secure Patient Registration Form
We want to welcome your child into our practice. Our goal is to make his/her dental experience pleasant and educational. Please provide us with all information requested so that we can better understand and care for your child.
Patient Name*

First NameLast Name
Sex*

MaleFemale
Birth Date*

MonthDayYear
Age
Siblings and Ages
Phone*

Area CodePhone Number
Parent's Email *
School
Grade
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Visit
Health Information:
Has your child ever had difficulty with any of the following: (Please check all that apply)
Check all that apply:

AIDS/HIVAnemiaAsthmaBehavioral ProblemsBladder DiseaseBleeding DisordersBlood TransfusionsCancerCerebral PalsyChicken PoxConvulsionsDiabetesEmotional ProblemsEpilepsyHearing DisordersHeart ConditionHepatitisKidney DisorderLiver DisorderLung DiseaseMeasles/MumpsMental RetardationMononucleosisOtherPregnancyRespiratory ProblemsRheumatic FeverSinus ProblemsThyroid DisordersTuberculosisVision Disorders
Please describe all above conditions that apply:
Is your child in good health?

YesNo
Are immunizations up-to-date?*

YesNo
Is your child taking any medicines or drugs:*

YesNo
Has your child ever been hospitalized or had surgery?*

YesNo
Does your child have a heart murmur or condition requiring Prophylactic Antibiotic coverage before dental treatment?*

YesNo
Does your child have any allergies (drugs or latex)*

YesNo
If yes, please specify:
Child's Pediatrician
Last Visit:

MonthDayYear
Phone

Area CodePhone Number
Has your child been seen by another dentist?

YesNo
If yes, Name of Dentist
Last Visit:

MonthDayYear
Phone

Area CodePhone Number
X-Rays:

YesNo
Has your child ever had an unfavorable dental experience?
How often does your child brush (i.e. once per day, twice per day):
Who is responsible for teeth cleaning?

ChildParentBoth
Was your child breast fed?

YesNo
Was your child bottle fed?

YesNo
Age Discontinued
Does your child: (Please check all that apply)

Bite/Chew nailsChew hard objectsClench jawGrind teethPacifierSuck thumb/FingerSuck/Bite lips
What is your home water source?

Public SystemPrivate WellBottled WaterOther
Because your child is a minor, it is necessary that signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment is performed. The signature of a parent or guardian affixed below authorizes the completion of all agreed upon dental treatment and the use of those methods appropriate there to. This consent shall remain in full force and effect until cancelled by either party. Furthermore, the undersigned agrees to be responsible for any bill incurred on this child for dental treatment should named responsible party fail or insurance benefits be denied.
Signature of Parent of Guardian:*
Date

MonthDayYear
Who is Accompanying the Child today?
Full Name

First NameLast Name
Relationship:
Do you have legal custody of this child?
Is your child adopted?

YesNo
Child lives with:

Both ParentsMomDadGrandparentsGuardian
I have listed below two persons who might be involved in his/her dental updates and/or transportation
1.
2.
Parent or Guardian Information
Father's Name

First NameLast Name
DOB

MonthDayYear
Home Address (If Different From child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Employer
Occupation
Marital Status

MarriedDivorcedWidowedSingle
Mother's Name

First NameLast Name
DOB

MonthDayYear
Home Address (If Different From child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Employer
Occupation
Marital Status

MarriedDivorcedWidowedSingle
Emergency Information
Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Primary Insurance Information
Name Of Insured

First NameLast Name
Insured Date of Birth

MonthDayYear
ID Number
Group Number
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insured's Employer Name
Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient's Relationship To Insured

SelfSpouseChildOther
Insurance Plan Name
Phone

Area CodePhone Number
Insurance Plan Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Referral Information
Who can we thank to referring you to this office?*

Another PatientDental OfficePediatricianYellow PagesWebsiteNewspaperSchoolWorkOther
I authorize the dentist to release any information to third party payers and /or other health practitioners, if necessary. I authorize and request my insurance company to pay directly to the dentist benefits otherwise payable to me.
Today's Date

MonthDayYear
Should be Empty:

Secure Patient Registration Form

Health Information:

Who is Accompanying the Child today?

Parent or Guardian Information

Emergency Information

Primary Insurance Information

Referral Information