256-593-3211

Map & Directions >>

Office Hours

Monday - Wednesday
8 a.m. - 5 p.m.
Thursday
7 a.m. - 2 p.m.
Friday
By Appointment Only

701 Medical Center Pkwy.
Boaz, AL 35957

256-593-3211

Map & Directions >>

Office Hours

Monday - Wednesday
8 a.m. - 5 p.m.
Thursday
7 a.m. - 2 p.m.
Friday
By Appointment Only

Child Patient Forms

Child Registration FormNeww - Dental

Patient Information

* Patient Name: (Required)

Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:
home cell

* E-mail (Required):

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent/Guardian Information

Parent Marital Status: Single Married Divorced Widowed Significant Other

Mother Step-Mother Guardian Other

Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip

Phone Number:
home cell

Secondary Phone Number:
home cell

Employer's Name:

Occupation:

Father StepFather Guardian Other

Name:

Social Security Number:

Birth Date:

Driver License Number:

Address (if different than child's):

City:

State:

Zip:

Phone Number:
home cell

Secondary Phone Number:
home cell

Employer's Name:

Occupation:

Emergency Contact Information

Emergency Contact Name (other than parent):

Phone Number:

Relation to child:

Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically related information to concerning child:
Relation(s) to child:

Insurance Information

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Co-pay (if known):

Deductible (if known):

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holders Name:

Relation:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Co-pay (if known):

Deductible (if known):

Dental History

How did you hear about our Practice? Ad Internet Family/Friend Physician Other Name of person referring (if applicable):

Have we treated any other family members? Yes No
Name

Have your child's tonsils or adenoids been removed? Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Does your child you have any missing or extra permanent teeth? Yes No

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

Does your child have speech problems? Yes No
If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply)?

Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing

Nail biting Thumb/Finger Sucking Chewing/Eating Problems

Medical History

Is your child currently being treated by a physician? Yes No
Reason:
Physician:
Last Visit:

Phone:

Does your child have any allergies/sensitivities to medications or latex? Yes No
If yes, please list:

Is your child currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Has puberty and/or menstruation begun? Yes No N/A

Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion? Yes No If yes, give approximate dates:

Is your child pregnant? Yes No
Nursing? Yes No
Taking birth control pills? Yes No

Check if your child has or have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date: