WELCOME FORM

WELCOME FORM

    Tell Us About Your Child:

    Health History:

    Is your child currently under the care of a physician? YesNo
    Please describe your child’s current physical health: GoodFairPoor
    Are immunizations current? YesNo

    Has your child had/experienced any of the following?

    YN Abnormal bleeding
    YN Allergies
    YN Any hospital stays
    YN Asthma
    YN Blood dyscrasias
    YN Cancer/tumors
    YN Congenital Birth Defect
    YN Diabetes
    YN Epilepsy
    YN Handicaps
    YN Heart murmur
    YN Hepatitis
    YN Hives
    YN Liver/CI problems
    YN Lupus
    YN Mentally physically disabled
    YN Mononucleosis
    YN Recurrent headaches
    YN Seizures
    YN Sight disorders
    YN Skin rash
    YN Tuberculosis
    1. Has your child ever been injured? YesNo
    2. Has your child had any operations? YesNo
    If so, when? For what reason?
    Was general anesthesia used? YesNo
    3. Does your child bruise easily?YesNo
    4. Has there ever been any history of spontaneous bleeding (e.g. nosebleeds) or prolonged bleeding following tooth removal surgery, cuts, etc.?YesNo

    Dental History:

    1. Please check reason(s) for seeking dental care:
    First ExaminationRoutine check-upToothache or swellingAppearance of teeth or faceCrowding TeethAccident
    Other
    2. Has your child has been to a dentist previously? YesNo
    a. When was the last visit? YesNo
    b. Have x-rays been taken and when?
    YesNo
    c. How would you describe your child’s temperament?
    3. How do you think your child will react to dental treatment?
    4. Has your child has fluoride in any of the following forms?
    Fluoride tablets or in vitamins (Fluoride amount .25 .5 1.0mg) YesNo
    Drinking water (community fluoridation) YesNo
    Topical application to teeth? YesNo
    When is last date of use
    Toothpaste; brand
    5. Does your child brush his/her own teeth? YesNo
    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast
    6. Do you brush your child’s teeth? YesNo
    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast
    7. Do you or your child use dental floss in cleaning your child’s teeth? YesNo
    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast
    8. Does your child have between meal snacks? YesNo
    9. Have your child’s teeth ever been injured?
    When?
    Cause?
    10. Does your child have any of the following habits? (Indicate ages when occured)
    Bottle to bed at night
    Thumb or finger sucking
    Pacifier
    Tongue thrusting
    Lip sucking or biting
    Breathes through mouth
    11. Has your child received any unusual dental or surgical treatment to the mouth? YesNo
    If so, what?

    Guarantor Information

    FATHER’S INFORMATION

    Name:
    Address:
    Home Phone:
    Relationship to Patient:
    Birthday:
    Social Security Number:
    Occupation:
    Employer:
    Address:
    Work Phone:

    MOTHER’S INFORMATION

    Name:
    Address:
    Home Phone:
    Relationship to Patient:
    Birthday:
    Social Security Number:
    Occupation:
    Employer:
    Address:
    Work Phone:

    In order to control the cost of dental services, we require that payment be made at the time of service, unless otherwise discussed previously with our Financial Coordinator. Payment can be made with cash, personal check, MasterCard or Visa. if for any reason your check is returned to us, there will be an additional fee.

    Please indicate the person responsible for payment:

    Name:
    Billing Address:
    City:
    Zip:
    Home Phone #:

    AUTHORIZATION AND RELEASE

    CONSENT FOR TREATMENT

    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 my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dentist to release any information including the diagnosis and the record of treatment or examination rendered to my child during the period of such care to third party payers and/or health practitioners. I authorize the use of radiographs and photographs for the purpose of teaching and scientific publications. I request that my insurance company pay directly to the dentist. I understand that my insurance carrier may pay less that the actual bill for services; therefore, I agree to be responsible for payment of all services rendered on my child’s behalf.

    Signature of Parents/Guardian:

    Connect with Us





      Fullerton Pediatric Dentistry

      ADDRESS
      100 E. Valencia Mesa Drive, Suite 102
      Fullerton, CA 92835

      PHONE
      714.992.5437 (KIDS)

      WEBSITE
      www.fullertonpediatricdentists.com

      OFFICE HOURS
      Monday-Thursday
      *9:00 AM to 12:00 PM & 2:00 PM to 5:00 PM
      Friday & Saturday
      *By Appointment Only