Child's Last Name : First Name : : Middle :
Nickname : Date Of Birth : Age :


Has child ever been examined
by another dentist?
Yes
No

Previous dentist : Date :

Any unhappy dental experiences :
Orthodntic appliances or braces worn
now or ever been worn ?

Unfavorable reaction to anesthesia?

Purpose of this visit :
Do You desire complete dental
services for this child?

Child's attitude to denstisry :
Normal Shy Apprehensive Frightened
Does your child brush teeth daily?

Do You assist your child with
tooth brushing?

Is Fluoride taken?
Any injuries to mouth teeth, head?

Any mouth habits-thumb sucking,
nail biting,mouth breathing,nursing
bottle habits,pacifier,etc?
Any unusual speech habits?
Any missing of extra teeth?
Have missing teeth been replaced?
Child's Physician : Address : Phone :

Date Of Last Physical Examination : Results :

Is child under care of physician now?
Yes No
Is child receiving medication or drugs?

What? Yes No
Is there any excessive bleeding when cut?
Yes No
Has child ever been hospitalized?
Yes No

Has child ever had surgery?
Yes No

Is there any allergy to penicillin
or other drugs?
Which? Yes No

Are there other allergies: food, pollen,
animals, dust? Yes No
Does Child have physical coordination
problems? Yes No
Are there any emotional problems?
Yes No
Are your child's vaccinations up to date?
Yes No
Has your child ever had a blood transfusion?
Yes No
Is your child adopted? Yes No
  Does he/she Know? Yes No


Has your child had any history of ,or difficulty with any of the following?
Heart Cerebral Palsy Mitral Valve Artificial bone Tourette Syndrome Cortisone Hepatitis Hiv/Aides Tuberculosis Drug/Alcohol abuse Mental Retardation Asthma Rheumatic Fever Diabetes ADD/ADHD Psyc Treatment Anemia Epilepsy Handicapi Cancer Thyroid Fever Blisters Hemophilia Hearing Bulimia Growth disorder Sinus
Please describe any current medical treatment including drugs,pending surgery,recent injuries or any other
information I should be aware of that we have not discussed
:

I CERTIFY THAT I AM THE DULY AUTHORIZED AGENT OF THE PATIENT AND THAT I HAVE READ AND I UNDERSTAND THE ABOVE QUESTIONS. I WILL NOT HOLD DR. SHEBANI OR HER ASSOCIATES , OR ANY MEMBER OF HER STAFF, RESPONSIBLE FOR ANY ERRORS OR OMMISIONS THAT I HAVE MADE IN COMPLETION OF THIS FORM.

Signature : Date :

Relationship to child :

Patient information

Child's Last Name :

First :

Middle :

Nickname :

Sex

M F
  Date of Birth :
Age :
Child's Address (Street) :
City :

State :

Zip Code :
Phone :
Child's School/Preschool : Grade :
Father'Full Name
Mother's Full Name

Father'Address :

Mother's Address :

City : State Zip
City : State Zip
Home Phone Cell Phone
Home Phone Cell Phone
Occupation :
Occupation :

Name Of Employer :
Name Of Employer :

Work Phone :
Work Phone :

Dental Insurance Company :
Dental Insurance Company :

Social Security Number :
Social Security Number :

Group # : Date Of Birth
Group # : Date Of Birth
Email :
Email :

Do Father,Mother,and Child all live together?
If parents cannot be reached,Friends or Relative to notify should an emergency arise.
Name : Relationships :
   Phone
Has any member of your family been a patient in this office ? Yes No Name Of Siblings :
How did You Hear About Us?
Family's General Dentist
Date of Child's last exam and cleaning and name of Dentist :

Consent and Assignment for the Treatment of a Minor

The undersigned hereby authorizes Dr.Amna shebani and Associates (Dentistry for children) to perform the examination and after explanation,the necessary dental services and those methods she deems appropriate in her professional judgement for the care of the above-named child.This authorization that my insurance benefits be paid directly to the dentist and i remain in full force and effect until cancelled by either party.

Signature :
Relationship to child :

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