1112 Trinity LaneBloomington, IL 61704309.663.7339 PediatricSmilesOfBloomington.com

Patient Info

Today’s Date: ______________

Child’s Name: ______________________________________________________________ Child’s Birthdate: _____/_____/_____ Child’s Age: ____

Nickname: _______________________________________ q Male q Female School: ________________________________ Grade: ____

Contact number to confirm appointments: _____________________ Whom may we thank for referring you? __________________________________

What is the primary reason for today’s visit? _____________________________________________________________________________________

Medical History

Child’s Physician: _____________________________________ Phone: (_________) ____________________________ Date of last visit: ________

Address: _______________________________________________________________________________________________________________

Is your child currently under the care of a physician? q Yes q No Please explain: _____________________________________________________

Does your child have social/personality/temperament concerns that we should be aware of? ________________________________________________

Please describe your child’s current physical health: q Good q Fair q Poor Are immunizations current? q Yes q No

Please list all medications and dosage that your child is currently taking: _________________________________________________________________

Please list all drugs and/or things that cause your child allergic reactions: ________________________________________________________________

Anything you would like to discuss with the Doctor in private? q Yes q No

Has your child had/experienced any of the following: (please circle)

Thomas D. Hall, D.M.D.Sara Rauen Dardis, D.D.S., M.S.

Y N Abnormal BleedingY N ADD / ADHDY N AIDS / HIV+Y N AllergiesY N AnemiaY N Any Hospital StaysY N Any OperationsY N ArthritisY N AsthmaY N Autism/AspergersY N Breathing / Lung Problems

Y N Cancer / TumorsY N Chicken PoxY N Congenital Birth DefectY N Congenital Heart DefectY N DiabetesY N Endocrine System DisordersY N EpilepsyY N Frequent InfectionsY N Behavior / Learning DisabilitiesY N Mentally / Physically DisabledY N Hearing Impaired

Y N Heart MurmurY N HemophiliaY N HepatitisY N High Blood PressureY N HivesY N Kidney ProblemsY N Liver / GI System ProblemsY N Low Blood PressureY N MeaslesY N Mitral Valve ProlapseY N Mononucleosis

Y N PregnancyY N Recurrent HeadachesY N Rheumatic FeverY N SeizuresY N Sickle Cell AnemiaY N Vision ProblemsY N Skin RashY N TonsilitisY N Tuberculosis (TB)

Y N Lip sucking and nail bitingY N Thumb/finger suckingY N Tongue thrust

Y N Chewing on objectsY N Nursing bottle habitsY N Mouth breathing

Y N Jaw painY N Tongue/cheek bitingY N Speech problems

Y N Clenching/grinding teethY N Used pacifierY N Breastfed

Please discuss any serious medical problems your child experiences, now or in the past: _____________________________________________________

______________________________________________________________________________________________________________________

Dental History

Is your child currently in pain? q Yes q No Is this your child’s first dental visit? q Yes q No

Has your child experienced problems with previous dental work? q Yes q No If so, explain: ____________________________________________

Previous Dentist: ___________________________________________ Date of last visit: ________________ Date of last X-Ray: ________________

Have there been any injuries to your child’s teeth, jaws, falls, blows, chips, etc.? . . . . . . .q Yes q No

Does your child take fluoride vitamins or drink fluoridated water? . . . . . . . . . . . . . . . . . . . .q Yes q No

Has your child been seen by an orthodontist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .q Yes q No Who? __________________________________

Does your child brush his/her teeth daily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .q Yes q No How often? _______ Do you assist? q Yes q No

Does your child floss his/her teeth daily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .q Yes q No How often? _______ Do you assist? q Yes q No

Does/did your child have any of the following habits? (please circle)

Last First MI

Street City State Zip

1112 Trinity LaneBloomington, IL 61704309.663.7339 PediatricSmilesOfBloomington.com

Parent’s Information

Family’s E-Mail: ___________________________________________________

Mother or Guardian: Marital Status: q Married q Single q Divorced q Widowed

Home Phone: ( _______ ) ______________ Work Phone: ( _______ ) ______________ Cell Phone: ( _______ ) ______________________________

Name: ____________________________________________________ Social Security #: _______________________ Birthdate: ____/____/ _____

Address: _______________________________________________________________________________________________________________

Employer: ________________________________________________ Occupation: ___________________________________________________

Father or Guardian: Marital Status: q Married q Single q Divorced q Widowed

Home Phone: ( _______ ) ______________ Work Phone: ( _______ ) ______________ Cell Phone: ( _______ ) ______________________________

Name: ____________________________________________________ Social Security #: _______________________ Birthdate: ____/____/ _____

Address: _______________________________________________________________________________________________________________

Employer: ________________________________________________ Occupation: ___________________________________________________

Name of parent who resides with the child: ______________________________________________

Emergency Contact: _____________________________ Relationship: _______________________________ Phone: ( _______ ) ________________

Is your child covered by a dental insurance plan? q Yes q No

Insurance Information

Primary Dental Insurance

Insured’s Name: _____________________________________________________ Relationship to Patient: __________________________________

Insured’s Address (if different from above): ______________________________________________________________________________________

Insured’s Birthdate: ____/____/_____ Social Security #: ______________________ Insured’s Employer: ___________________________________

Insured’s Employer Address: ____________________________________________________________________ Phone: ( _______ ) _____________

Insurance Co. Name: ___________________ Phone: ( _____ ) ___________ Group # ____________________ ID# ___________________________

Insurance Co. Address: ____________________________________________________________________________________________________

Secondary Dental Insurance

Insured’s Name: _____________________________________________________ Relationship to Patient: __________________________________

Insured’s Address (if different from above): ______________________________________________________________________________________

Insured’s Birthdate: ____/____/_____ Social Security #: ______________________ Insured’s Employer: ___________________________________

Insured’s Employer Address: ____________________________________________________________________ Phone: ( _______ ) _____________

Insurance Co. Name: ___________________ Phone: ( _____ ) ___________ Group # ____________________ ID# ___________________________

Insurance Co. Address: _____________________________________________________________________________________________________Financial Responsibility

I assume financial responsibility for all dental treatment and medications provided for my child, and understand that payment is expected on the date services are provided. I request and authorize my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and I therefore am ultimately responsible for payment of services rendered on my behalf or my dependents.

Signature: __________________________________ Relationship: ___________________________________________ Date: ________________

Authorization and ReleaseTo the best of my knowledge the information I have given on this form is correct, and I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or exam rendered to my child during the period of such dental care to third party payors and or their health practitioners.

If I request, I will be provided a copy of this office’s Notice of Privacy Practices. I consent to their use and disclosure of my children(s) Protected Health Information to carry out treatment, payment activities and healthcare operations.

Signature: __________________________________ Relationship: ___________________________________________ Date: ________________

Thomas D. Hall, D.M.D.Sara Rauen Dardis, D.D.S., M.S.

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