BACKGROUND INFORMATION

Child’s name
Date of Birth
Child's Soc. Sec. #   
Male Female
Child’s preferred name(nickname)
Child's residence
City State Zip 
Hobbies      
Likes  
Dislikes
Siblings (with age)
Are siblings patients of Great Grins?   Yes  No 
Whom may we thank for referring you to our practice?
In case of emergency, whom (other than parent/ guardian) should we notify?
Relationship     Phone #

RESPONSIBLE PARTY INFORMATION
    Person financially responsible for this account
Phone#
Father/Guardian’s name
Father’s address (if different from child's)
Social Security #
Drivers license #
      Marital Status: Single   Married   Divorced
Widow Widower
Home phone #
Other phone #
Father’s Employer
How long/position
Employer’s Address
Business phone Ok to call? Yes  No 
Mother/Guardian’s name
Mother’s address (if different from child's)
Social Security #
Drivers license #
      Marital Status: Single   Married   Divorced
Widow Widower
Home phone #    
Other phone #
Mother’s Employer
How long/position
Employer’s Address
Business phone Ok to call? Yes  No 
Who is the custodial parent / legal guardian?

DENTAL INSURANCE
Primary insured name
Date of birth
SS#
Name of insurance co.
Telephone of insurance co.
Address of insurance co.
Program or policy #  
Group #

Health History
Dental History- please answer all questions
What is the reason for your child’s visit today?
Date of last dental visit
Last dental cleaning
What was done at the last dental visit?
Previous dentist’s name
Address    
 City/State Telephone
Any problems with previous dentists?    Yes  No   
Explain
How often has your child had dental examinations? 
Does your child have any dental problems now? 

Medical History- please answer all questions
In your opinion, is your child healthy?  Yes  No 
if no, why not?
Who is your child's physician?
Phone
Address City/State
Zip
Has your child been under the care of a medical doctor during the past two years? 
Yes  No 
If yes, for what?
Has your child taken any medication or drugs during the past two years?         
Yes  No 
If yes, please list name and dosage
Is your child currently taking any medications?             Yes  No 
If yes, what medications and for what condition(s)
Is your child allergic to any medication or substance? Yes  No 
List
Is a parent allergic to any medication or substance? Yes  No 
List
Indicate which of the following your child has or had. 

Heart problems   Yes  No 
High blood pressure    Yes  No           
Low blood pressure Yes  No 
Heart valves    Yes  No 
Valley fever Yes  No 
Rheumatic fever Yes  No 
Heart Murmur  Yes  No 
Artificial joints  Yes  No 
Epilepsy Yes  No 
Cleft palate/lip Yes  No 
SeizuresEmotional problems Yes  No 
Tuberculosis Yes  No 
Frequent colds Yes  No 
Ulcers Yes  No 
Liver disease Yes  No 
Diabetes Yes  No 
Endocrine problems Yes  No 
Hyperthyroidism Yes  No 
Hypothyroidism Yes  No 
Anemia Yes  No 
Hemophilia Yes  No 
Sickle cell anemia        Yes  No          
Excessive bleeding Yes  No 
Bruise easily Yes  No 
HIV/AIDS Yes  No 
Blood transfusion Yes  No 
Hepatitis A/B/C          Yes  No          
Cancer     Yes  No                           
Tumors Yes  No 
Radiation therapy     Yes  No           
Drug/chemotherapy       Yes  No        
Kidney problems Yes  No 
STD's       Yes  No                           
Arthritis              Yes  No                
Vision problems Yes  No 
Behavioral problems          Yes  No     
Mononucleosis            Yes  No           
Persistent nose bleeds Yes  No 
Fainting spells        Yes  No              
Dizziness           Yes  No                  
Ringing in ears      Yes  No    
Bladder problems      Yes  No             
Headaches         Yes  No                  
Asthma Yes  No 
RSV        Yes  No                                        
Low birth weight/SIDS    Yes  No   
Last Asthma attack:
Allergies, if so, to what  
Other, please describe
Is your child current with his/her immunizations?   Yes  No 
If No, why not?
Is there anything else about you or your child's health history that we should know?   
Yes  No 
If yes, please describe
Do you wish for more privacy when discussing your child’s health history?
Yes  No 
12 and older: Do you:     
Smoke or use chewing tobacco? Yes  No
Drugs?  Yes  No 
Alcohol?  Yes  No 
Teens:   Are you pregnant?           Yes  No   
If so, how many months? Nursing?   Yes  No 
Taking birth control pills? Yes  No 

CONSENT AND RELEASE

Please note: It is the policy of Great Grins Children's Dentistry, P.L.L.C. not to allow parents to accompany their children into the treatment area when restorative treatment is being performed (ex. fillings).  The primary purpose of such a policy is to allow our staff to develop a trusting, working relationship with your child.  Experience has shown us that children actually do better without their parents in the treatment area.  You are welcome to come into the treatment area for other visits (ex. cleanings).

ADDITIONAL TERMS
Cleaning/examination appointments canceled with less than 24 hours notice are subject to a $50.00 cancellation charge and this charge must be paid before additional appointments may be scheduled.  Missing a scheduled treatment appointment (ex. fillings/sedation) without a 48 hour notice or valid excuse may result in a $50.00 charge or being refused further appointments. Arriving more than 10 minutes late for a scheduled appointment may result in the appointment being rescheduled, less treatment being performed or an increase in fees.  Checks returned by the bank are subject to a $20.00 processing charge and no further appointments will be scheduled unless payment is received in full prior to such appointments.  Such payment must be by certified check.  Accounts unpaid after 30 days from the date of billing are subject to a finance charge at the rate of 1% per month (12% per year).  Should the account be referred to for collection, you will be responsible for collection costs, together with court costs and reasonable attorneys' fees.

RELEASE: I authorize Great Grins Children's Dentistry, P.L.L.C. (Angela M. Wolfman, D.D.S. & Kedar S. Lele, D.D.S.) to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I hereby authorize payment of insurance benefits directly to Great Grins Children's Dentistry, P.L.L.C., otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services.  I understand I am financially responsible for payment in full of all accounts and, if my insurance carrier does not pay the claim within 60 days, the claim becomes my responsibility.  By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

I understand the above information is necessary to provide my child with dental care in a safe and efficient manner.  I have answered all questions correctly and fully and to the best of my knowledge.  Should further information be needed, you have my permission to ask the respective health care provider or agency, which may release such information to you.  I will promptly notify you of any change in my child's health or use of medications.