Childs Last Name First Middle Nickname Sex Date of Birth Age
M F 
Child’s Address
(Street)
City State Zip Code Phone
Child’s School/Preschool Grade
Father’s Full Name Mother’s Full Name
Father’s 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/ ID Social Security Number/ ID
Group # Date of Birth Group # Date of Birth
E-Mail E-Mail
Do Father, Mother and Child all live together?
If Parents cannot be reached, Friend or Relative to Notify should an emergency arise.
Name Relationship Phone
Has any member of your family been a patient in this office Yes No
Name of Siblings How did 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 judgment for the care of the above-named child. This authorization includes the release of my child’s medical records if deemed necessary for the proper care of my child. I further authorize that my insurance benefits be paid directly to the dentist and understand that I am financially responsible to the dentist for all the charges not covered by my insurance. The consent shall remain in full force and effect until cancelled by either party.

Signature Date

Relationship to Child

Childs Last Name First Middle Nickname Date of Birth Age
1. Has child ever been examined by another dentist?Previous dentist Date   1. Purpose of this visit
2. Has child complained about dental problems?   2. Do you desire complete dental services for the child?
3. Any unhappy dental experiences   3. Child’s attitude to dentistryNormal Shy Apprehensive Frightened
4. Any injuries to mouth, teeth, head?   4. Does your child brush teeth daily?
5. Any mouth habits – thumb sucking, nail biting, mouth Breathing, nursing bottle habits, pacifier, etc?   5. Do you assist child with tooth brushing?
6. Any unusual speech habits?   6. Is fluoride taken?
7. Any missing or extra teeth?    
8. Have missing teeth been replaced?    
9. Orthodontic appliances or braces worn now or ever been worn?    
10. Unfavorable reaction to anesthesia?    
Child’s Physician Address Phone
Date of Last Physical Examination Results
  Yes No   Yes No
1. Is child under care of physician now?  Yes No 7. Are there other allergies: food, pollen, animals, dust?  Yes No

2. Is child receiving any medication or drugs?

What?

 Yes No 8. Does child have physical coordination problems?  Yes No
3. Is there any excessive bleeding when cut?  Yes No 9. Are there any emotional problems?  Yes No
4. Has child ever been hospitalized?  Yes No 10. Are your child’s vaccinations up to date?  Yes No
5. Has child ever had surgery?  Yes No 11. Has your child ever had a blood transfusion?  Yes No
6. Is there any allergy to penicillin or other drugs?  Yes No

12. Is your child adopted?

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. AMNA SHEBANI OR HER ASSOCIATES, OR ANY MEMBER OF HER STAFF, RESPONSIBLE FOR ANY
ERRORS OR OMMISIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.

SIGNATURE DATE

RELATIONSHIP TO CHILD

Menu Title