New Children Patient Form

Fill Out The Form Below if Your Child is a New Patient

1. About Your Child

1. About Your Child

Today’s Date

Child’s Name

Child’s Nickname

Boy or Girl

Birthdate

Age

School

Grade

Address

2. Child’s Family Information

2. Child’s Family Information

Who is accompanying this child?

Relation to child?

Do You Have Legal custody of Child?

How many Brothers/Sisters?

Ages?

Mother’s Name?

Address

Phone

Date of Birth

Employer

How Long?

Employer’s Address

Father’s Name

Address

Phone

Date of Birth

Employer

How Long?

Employer’s Address

3. Insurance Information

3. Insurance Information

Co. Name

Address

Phone

Group #

Insured Name

Relation

Date of Birth

Insured’s Employer

4. Account Info

4. Account Info

Name

Relation

Billing Address

Phone

5. Child’s Dental Information

5. Child’s Dental Information

Reason for Today’s Visit

Is Child in Pain

What dental Problems has the child had?

Does child require pre-medication?

Previous Dentist

Last Dental Exam

Last Dental X-rays

Times a Day Child Brushes

Times a Week Child Flosses?

Is the childs’s water Fluoridated?

How would you rate the child’s smile?

6. Child’s Medical History

6. Child’s Medical History

Is Child taking medications?

Child’s Physician

Phone

Address

Last Medical Exam

What medical conditions does the child have?

Does child have allergies?

Rate the child’s general health?

Has the child taken Ritalin?

Child’s Blood Type?

8580 River Road Southport, NC 28461

info@jwilliamsdentistry.com

Business Hours

Monday: Closed

Tues: 8:15 am – 3:00 pm Lunch: 12:30 pm - 1:00 pm

Wed: 8:15 am – 5:00 pm Break: 12:00 pm - 1:00 pm

Thurs: 8:15 am – 3:00 pm Lunch: 12:30 pm - 1:00 pm

Friday: 8:15 am – 2:00 pm

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