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 Name Last Name
Sex *

Male Female
Birth Date *

Month Day Year
Age
Siblings and Ages
Phone *

- Area Code Phone Number
Parent's Email *
School
Grade

Child's Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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/HIV Anemia Asthma Behavioral Problems Bladder Disease Bleeding Disorders Blood Transfusions Cancer Cerebral Palsy Chicken Pox Convulsions Diabetes Emotional Problems Epilepsy Hearing Disorders Heart Condition Hepatitis Kidney Disorder Liver Disorder Lung Disease Measles/Mumps Mental Retardation Mononucleosis Other Pregnancy Respiratory Problems Rheumatic Fever Sinus Problems Thyroid Disorders Tuberculosis Vision Disorders
Please describe all above conditions that apply:
Is your child in good health?

Yes No
Are immunizations up-to-date? *

Yes No
Is your child taking any medicines or drugs: *

Yes No
Has your child ever been hospitalized or had surgery? *

Yes No
Does your child have a heart murmur or condition requiring Prophylactic Antibiotic coverage before dental treatment? *

Yes No
Does your child have any allergies (drugs or latex) *

Yes No
If yes, please specify:
Child's Pediatrician
Last Visit:

- Month - Day Year
Phone

- Area Code Phone Number
Has your child been seen by another dentist?

Yes No
If yes, Name of Dentist
Last Visit:

- Month - Day Year
Phone

- Area Code Phone Number
X-Rays:

Yes No
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?

Child Parent Both
Was your child breast fed?

Yes No
Was your child bottle fed?

Yes No
Age Discontinued
Does your child: (Please check all that apply)

Bite/Chew nails Chew hard objects Clench jaw Grind teeth Pacifier Suck thumb/Finger Suck/Bite lips
What is your home water source?

Public System Private Well Bottled Water Other
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

- Month - Day Year
Who is Accompanying the Child today?
Full Name

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

Yes No
Child lives with:

Both Parents Mom Dad Grandparents Guardian
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 Name Last Name
DOB

Month Day Year

Home Address (If Different From child)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
E-mail
Employer
Occupation
Marital Status

Married Divorced Widowed Single
Mother's Name

First Name Last Name
DOB

Month Day Year

Home Address (If Different From child)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
E-mail
Employer
Occupation
Marital Status

Married Divorced Widowed Single
Emergency Information
Name *

First Name Last Name
Relationship *
Phone Number *

- Area Code Phone Number
Primary Insurance Information
Name Of Insured

First Name Last Name
Insured Date of Birth

Month Day Year
ID Number
Group Number

Insured's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insured's Employer Name

Employers Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Patient's Relationship To Insured

Self Spouse Child Other
Insurance Plan Name
Phone

- Area Code Phone Number

Insurance Plan Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Referral Information
Who can we thank to referring you to this office? *

Another Patient Dental Office Pediatrician Yellow Pages Website Newspaper School Work Other
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

- Month - Day Year
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