specialsmilesdentistry.net

Patient Information
*

Patient First Name Middle Name Last Name
Child prefers to be called *
Gender *

Male Female
Birthdate *

Month Day Year
Patient Social Security Number *
Street Address or P.O. Box *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *
Responsible Party Information
Guardian 1 Information
*

Miss Ms. Mrs. Mr.
*

First Name Middle Name Last Name
Birthdate *

Month Day Year
Relationship to Patient *
Address is same as patient *

Yes No
Street Address or P.O. Box *

Street Address

Street Address Line 2

City State

Zip Code
Marital Status *

Single Married Separated Divorced Other
Home Phone *
Work Phone *
Mobile Phone *
Preferred Email *
Social Security Number *
Occupation *
Employer *
Employer Phone Number *
Guardia 2 Information
*

Miss Ms. Mrs. Mr.
First Name Middle Name Last Name
Birthdate *

Month Day Year
Date
Relationship to Patient *
Address is same as patient *

Yes No
Street Address or P.O. Box *

Street Address

Street Address Line 2

City State

Zip Code
Marital Status *

Single Married Separated Divorced Other
Home Phone *
Work Phone *
Mobile Phone *
Preferred Email *
Social Security Number *
Occupation *
Employer *
Employer Phone Number *
Insurance Information
Is this patient covered by insurance? *

Yes No
If yes, does the patient have dual coverage? *

Yes No
Primary Insurance
Provider *
Address *
Phone *
Insurance ID/Social Security Number *
Group # *
Policy # *
First Name of Insured Middle Name Last Name
Relationship to Insured
Street Address or P.O. Box

Same as Guardian 1 Same as Guardian 2
Street Address or P.O. Box *

Street Address

Street Address Line 2

City State

Zip Code
Birthdate *

Month Day Year
Home Phone *
Mobile Phone *
Employer *
Employer Phone *
Secondary Insurance
Provider *
Address *
Phone *
Insurance ID/Social Security Number *
Group # *
Policy # *
Co-Pay Amount *
First Name of Insured Middle Name Last Name
Relationship to Insured
Street Address or P.O. Box

Same as Guardian 1 Same as Guardian 2
Street Address or P.O. Box *

Street Address

Street Address Line 2

City State

Zip Code
Birthdate *

Month Day Year
Home Phone *
Mobile Phone *
Employer *
Employer Phone *
Referral Program
Who may we thank for referring you to us? *
Name of Dentist *
Name of Doctor *
Name of Advertisement *
Current Special Smiles Family
Emergency Contact
Name of local friend or relative *
Relationship to patient *
Home Phone *
Mobile Phone *
Patient Medical History
Primary Doctor
Phone
Date of last physical exam

Month Day Year
Is your child under care of physician currently?

Yes No
Reason of physician
List any prescribed medications
List any surgeries or hospital visits
Has your child experienced dental trauma?

Yes No
Medical History (Check all that apply):

Acid Reflux ADHD/ADD A.I.D.S./H.I.V. Anemia Asthma Autism Bladder Problems Bone/Muscle Problems Bruise Easily Cancer Cerebal Palsy Cleft Lip/Palate Convulsions Developmental Disability Diabetes Eating Disorder Epilepsy Eye Condition Fainting Genetic Syndrome/Disorder Hay Fever Hearing Impairment Heart Murmur/defect Hemophilia Hepatitis/Liver Disease Implants/Shunt Jaundice Kidney Disease Liver Disease Metabolic Disorder Premature Birth Psychiatric Care Sickle Cell Anemia/Trait Sleep Apnea Speech Disorder Stomach/GI Disorders Thyroid Disease Tuberculosis
Is your child allergic to any of the following (Check all those that apply):

Penicillin Local Anesthetics General Anesthesia Sulfa Drugs Amoxicillin Sedatives Latex
Is this your child’s first visit to the dentist?

Yes No
Name of previous dentist
Phone *
Date of Last Visit *

Month Day Year
Please list any specific concerns about your child’s dental health
Please check all that apply to your child:

Flosses teeth daily Bites lips, nails or cheeks Sucks finger Uses a pacifier or bottle Bleeding gums Teeth sensitivity
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