Parent Information
Parent's Full Name
*
First Name
Last Name
Parent Date of Birth
*
-
Month
-
Day
Year
Date
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Parent Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Information
Child's Full Name
*
First Name
Last Name
Child Date of Birth
*
-
Month
-
Day
Year
Date
Will this be your child's first dental visit?
*
Yes
No
Last Dental Visit
*
Previous Dental Office Name
*
Current Dental Concerns
*
Typical Behavior at the Dental Clinic
*
Please Select
Calm & Cooperative
Quiet or Slow to Warm Up
Curious & Talkative
Needs Extra Reassurance
Sensitive to Sounds, Textures, or New Experiences
Active or Has Difficulty Sitting Still
Behavior Notes
*
Has the patient had dental X-rays before?
*
Yes
No
Not sure
If yes, approximately when were the most recent X-rays taken?
*
Does the patient have any special healthcare needs?
*
Yes
No
If yes, please describe the special healthcare needs
*
Medical concerns, allergies, medications, or conditions the team should know about
*
Please list any additional children for this appointment:
Insurance Information
How would you like to provide your dental insurance information?
*
Upload insurance card
Type in insurance information
I do not have dental insurance
Front of insurance card
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Back of insurance card
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Insurance carrier name
*
Subscriber's full name
*
First Name
Middle Name
Last Name
Subscriber's date of birth
*
-
Month
-
Day
Year
Date
Member ID
*
Employer name
*
Group number
*
Insurance provider phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Information
How did you hear about us?
*
Please Select
Friend or Family
Dentist
School
Google
Facebook Group
Online Review
Drove By
Returning Patient
Other
Whom can we thank for the referral?
Submit
Should be Empty: