New Patient Form - Dr. Parker Pediatric Dentist

PATIENT INFORMATION

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Today's Date:

Sex:

Patient Name:

First

Middle

Last

Nickname:

Mailing Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

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Phone Number:

If Minor, Parent / Guardian Name:

Other Children We May Have Seen:

Date of Birth:

SS#

Who May We thank For Referring You To Our Office:

RESPONSIBLE PARTY INFORMATION

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Parent Name:

First

Last

Marital Status:

Mailing Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

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Parent Phone Number:

Email:

Date of Birth:

Employer:

Work/Other Phone Number:

SS#

Relationship:

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Parent 2 Name:

First

Last

Marital Status:

Parent 2 Mailing Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

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Parent 2 Phone Number:

Email:

Date of Birth

Employer:

Work/Other Phone Number:

SS#

Relationship:

EMERGENCY CONTACT INFORMATION

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Emergency Contact's Name:

First

Last

Contact Number:

Emergency Contact's Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

INSURANCE PROVIDER

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Policy Holder Name:

Date of Birth:

Employer:

Insurance Company Phone Number:

SS#

Insurance Company:

Member ID:

Group #

DUAL COVERAGE?

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Policy Holder Name:

Date of Birth:

Employer:

Insurance Company Phone Number:

SS#

Insurance Company:

Member ID:

Group #

MEDICAL HISTORY

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Who Is Your Child's Pediatrician?

Regular Medical Exams? Yes/No

Immunizations Up to Date? Yes/No

Child Hospitalized Since Birth? Yes/No

Child In Good Health? Yes/No

Child Taking Medications? If yes, please list medications.

Unfavorable Reactions To Medicine? Please list medications.

Medical Conditions List:

DENTAL HISTORY

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1st Dental Visit? Yes/No

Fluoride Supplement? Yes/No

Pacifier? Yes/No

Age Bottle Discontinued:

Ever have An Unfavorable Experience? Yes/No

Finger Sucker? Yes/No

Trauma To Face or Jaw? Yes/No

Parish Water Source:

Appointment Reason:

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How Did You FIRST Hear About Us?

If a family member or friend referred you, who was it?

Date:

Electronic Signature

Clear Signature

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE PROVIDER

DUAL COVERAGE?

MEDICAL HISTORY

DENTAL HISTORY

Dr. Jason Parker

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