Child New Patient Registration

Child New Patient Registration

Confidential
How did you hear about our office? *
Referring Dentist
Who may we thank for referring you?
If other, please state:
Patient Full Name *

First Name Last Name
Gender *

Male Female
Birth Date *

Month Day Year
Parent/Guardian Cell Phone Number
Parent/Guardian E-mail
example@example.com
Home Address *
School Name
Grade
Hobbies
Parent/Guardian 1 *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
example@example.com
How would you like to receive appointment reminders?

Text Message Email
Check the Appropriate Box *

Father Mother Gaurdian Step Father/Mother
Parent/Gaurdian 1 Marital Status *
Parent/Guardian 2 (If none, type NONE)
Phone Number *

Area Code Phone Number
Email *
example@example.com
How would you like to receive appointment reminders?

Text Message Email
Check the Appropriate Box *

Father Mother Gaurdian Step Father/Mother
Parent/Gaurdian 2 Marital Status *
Will you be using your dental insurance for your child? *

Yes No
Insurance Subscriber's Information
Insurance Company *
Subscriber Name *

First Name Last Name
Social Security Number
(This may be required in order to verify eligibility and benefits)
Subscriber ID Number *
Subscriber Birth Date *

Month Day Year
Please upload pictures of your dental insurance card, both front and back

Browse Files

Cancel of
Medical History
Patient's Physician:
Phone Number
Last check-up date:
MM/YYYY

Please indicate if you have any of the following condition: *

Yes

Rheumatic fever

Drug allergies

Heart problems

Diabetes

Asthma

Epilepsy

High Blood Pressure

Bleeding problems

Convulsions

Sinus problems

Osteoporosis

Other

Are you currently under care of a physician?
Please indicate any allergies, or significant medical history that we need to be aware of. *
(N/A if Not Applicable)
Dental History
Patient's General Dentist or Children's Dentist: *
Phone Number *
Last check-up date: *
MM/YYYY

Please fill out the following:

Yes

Do you have any outstanding dental work to be completed?

Have you had any previous orthodontic treatment?

Has any of your family had orthodontic treatment?

Do you have any missing teeth?

Do you have any problem with eating or chewing?

Have you had any teeth removed?

Have you had any injury to your face, jaws, or teeth?

Are you currently experiencing any dental or facial pain?

Do you grind your teeth at night?

Do you snore at night?

Please indicate any dental history that we need to be aware of. *
(N/A if Not Applicable)
How would you rate your teeth? (Please rate from 1 = worst to 10 = Best)
What would need to improve on your SMILE so it is a perfect 10? 😃
How do you feel about getting braces?
How do you feel about Invisalign?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to the patient’s health. It is my responsibility to inform Dr. Shin of any changes in medical and/or dental status. I also authorize Dr. Shin, and staff to perform all the necessary procedures deemed appropriate to make a thorough diagnosis of the patient’s dental and oral facial needs.
Parent/Gaurdian Signature (If Patient is under 18) *

Clear
Please Print Name *

First Name Last Name
Relationship to the Patient: *
Today's Date: *
Should be Empty:

Insurance Subscriber's Information