Santa Clarita

18580 Via Princessa Suite 3, Santa Clarita, CA 91387

Porter Ranch

11239 Tampa Ave #208 Porter Ranch, CA 91326

For Parents
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Patient Resources

Home patient resources Porter Ranch Patient Forms

Porter Ranch Patient Forms

Patient Personal Information

Patient NameNick Name

Sex

Male

Female

BirthdayAgeGrade

SchoolNames & ages of siblings

Email address

Home phoneCell phoneWork phone

Home addressCityStateZip code

Who has legal custody of patient?

Father’s / Guardian’s nameFather’s / Guardian’s SSNFather’s / Guardian’s DOB

Mother’s / Guardian’s nameMother’s / Guardian’s SSNMother’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

NameRelationshipPhone number

Health History

Is your child in good health?

Yes

Date of last physical exam

Name of child’s physicianChild’s physician’s phone number

Has your child ever had a health problem?

Yes

If your child ever had a health problem, please describe here

Has your child ever been hospitalized or had surgery?

Yes

If your child ever has been hospitalized, please describe here

Was there excessive bleeding when cut?

Yes

If there was excessive bleeding when cut, please describe here

Is your child allergic to anything?

Yes

If child is allergic to, please describe here

Is your child currently taking any medications?

Yes

If child is taking any medications, please give medication and reason

Were there any problems at birth?

Yes

If there was any problem at birth, please describe

Please check if your child has been treated for any of the following:

Heart disease

Congenital birth defects

Mental delays

Liver/GI disease

Recurrent headaches

Physical delays

Kidney disease

Asthma

Thyroid disease

Speech/Hearing

Diabetes

Drug/Alcohol abuse

Cerebral palsy

Hepatitis

Tuberculosis

Cancer/Tumors

Cleft lip/palate

Bladder diff

Bleeding/Transfusions

Personality/Social

Chicken pox

Anemia

Strep throat

Measles/Mumps

Rheumatic fever

Blood dyscrasias

Dental History

Has your child ever had a dental visit?

Yes

Name of dentistPrevious visit date

Has your child experienced any unfavorable reaction from previous dental care?

Yes

If there were any unfavorable reactions from previous dental visit, please explain

Does your child suck a finger, thumb, or pacifier?

Yes

Does your child have pain with chewing, yawning, or wide opening?

Yes

Does your child breathe mainly through the mouth?

Yes

Does your child grind his/her teeth?

Yes

Does your child snore?

Yes

Please check if your child is having problems with any of the following:

Cavities

Toothache

Teeth Sensitive

Trauma

Gum Infections

Color of Teeth

Orthodontics

Jaw Sounds

Other

Please comment about health problems you checked above

Insurance Company

Insurance companyGroup #

Subscriber’s nameSubscriber’s DOB

Subscriber’s SSNRelationship to Patient

Is patient covered by additional insurance?

Yes

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance cover with the insurance company(ies) above and assign payment directly to doctor. I understand that I am financially responsible for all changes 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 signatureRelationshipDate

Consent for Dental Treatment

I request and authorize any 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 any doctor at Kidz Dental Care to diagnose and/or treat my child’s dental problem. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Any doctor at Kidz Dental Care 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 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 signatureDate

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