Patient Information Form
Patient Name
Patient Nickname
Birthday
Age
Grade
Sex
School
Names & Ages of Siblings
Home Phone
Cell Phone
Work Phone
Email
Home Address
Who has legal custody of patient?
Father's / Guardian's Information
Father's / Guardian's SSN#
Father's / Guardian's DOB
Mother's / Guardian's Information
Mother's / Guardian's SSN#
Mother's / Guardian's DOB
Whom may we thank for referring you to us?
What is the reason for your child's dental visit?
Emergency Contact
In the event of an emergency, whom should we contact? (Someone not living with you.)
Name (#1)
Relationship (#1)
Phone (#1)
Name (#2)
Relationship (#2)
Phone (#2)
Health History
Is your child in good health?
Date of Last Physical Exam
Name of Child's Physician
Physician's Phone
Has your child ever had a health problem?
Has your child ever been hospitalized or had surgery?
Is there excessive bleeding when cut?
Is your child allergic to anything? If so, what?
Is your child currently taking any medications?
Were there any problems at birth?
Please check if your child has been treated for any of the following:
Heart Disease
Liver/GI Disease
Kidney Disease
Speech/Hearing
Cerebral Palsy
Cancer/Tumors
Bleeding/Transfusions
Anemia
Rheumatic Fever
Seizures/Epilepsy
Congenital Birth Defects
Recurrent Headaches
Asthma
Diabetes
Hepatitis
Cleft Lip/Palate
Personality/Social
Strep Throat
Blood Dyscrasias
AIDS/HIV
Mental Delays
Physical Delays
Thyroid Disease
Drug/Alcohol Abuse
Tuberculosis
Bladder Diff
Chicken Pox
Measles/Mumps
Other Problems
Dental History
Has your child ever had a dental visit?
Has your child experienced any unfavorable reaction from previous dental care?
Does your child suck a finger, thumb or pacifier?
Does your child have pain with chewing, yawning, or wide opening?
Does your child breathe mainly through the mouth?
Does your child grind his / her teeth?
Does your child snore?
Please check if your child is having problems with any of the following:
Cavities: Toothache: Sensitivity:
Trauma: Gum Infection: Color of Teeth:
Orthodontics: Jaw Sounds: Other:
Insurance Company
Insurance Company
Group Number
Subscriber Name
Subscriber's DOB
Subscriber's SSN
Relationship to Patient
Is patient covered by additional insurance?
Insurance Company
Group Number
Subscriber Name
Subscriber's DOB
Subscriber's SSN
Relationship to Patient
Assignment and Release

I, the undersigned certify that I (or my dependent) have insurance coverage with the insurance company stated above and assign payment directly to doctor. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature
Relationship
Today's Date
Consent for Dental Treatment

I request and authorize Dr. Hirano, or any other doctor at Kidz Dental Care, to examine, clean, and provide dental treatment on my child's teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Hirano / Staff to diagnose and/or treat my child's dental problem. I will allow photographs to be taken of my child or child's teeth for diagnostic, educational, or marketing purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Hirano / Staff will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, using variable voice tone and stabilization with a pedowrap. I will be responsible for any charges incurred on this child for dental treatment.

I understand that collection actions may be taken if my balance goes beyond 90 days.

I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.

Parent/Guardian Signature
Today's Date