Patient Information

Patient Age(Required)

Preferred Language

Other Preferred Language(Required)

Name(Required)

First Middle Last

Preferred Name(Required)

Name child prefers to be called

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Birthday(Required)

Do you have other children in your family(Required)

Other Children

Name

Age

Names and ages of other children in your family

Whom may we thank for telling you about our office?

Family Information: Parent 1

Name(Required)

First Last

Parent Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer

Mobile Phone(Required)

Home Phone

Work Phone

Date of Birth(Required)

Email(Required)

Would you like to add another parent?(Required)

Family Information: Parent 2

Name(Required)

First Last

Address(Required)

Same as Parent 1

Street Address Address Line 2 City State ZIP Code

Mobile Phone(Required)

Home Phone

Work Phone

Date of Birth(Required)

Email(Required)

Emergency Informaton

Name(Required)

First Last

Name of nearest relative/friend not living with you

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Relationship(Required)

Is there a different party responsible for payment of your account than the parent(s) listed on the previous pages?(Required)

Name(Required)

First Middle Last

Residential Address(Required)

Street Address Address Line 2 City State ZIP Code

Years at this address(Required)

Please enter a number less than or equal to 99.

Mailing Address

Same as previous

Mobile Phone(Required)

Home Phone

Birthday(Required)

Relationship To Patient(Required)

Employer

Position

Business Phone

Does the party responsible for payment have a spouse?(Required)

Spouse's Name(Required)

First Middle Last

Spouse's Birthday(Required)

Spouse's Relationship To Patient(Required)

Spouse's Employer

Spouse's Position

Spouse's Business Phone

Dental Insurance

Insurance Name

Policy Holder's Name

Group #

Relationship

Date of Birth

Secondary Insurance

Employer

Dental History

Your Child's Dental History

Patient Name	Actions

There are no Histories.

Pediatric Medical History

Patient Name	Actions

There are no Pediatric Medical Histories.

Supplemental History for Infants/Toddlers

Ages 0–4

Patient Name	Actions

There are no Supplemental Histories.

Supplemental History for Adolescents

Patient Name	Actions

There are no Histories.

I understand that the information I am giving is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Parent/Guardian Name(Required)

Signature(Required)

Name	Domain	Purpose	Expiry	Type
_ga_PQPWWBWR91	rootspediatricdental.com	---	2 years	---
_ga	rootspediatricdental.com	Google Universal Analytics long-time unique user tracking identifier.	2 years	HTTP

New Patients

Patient Information

Family Information: Parent 1

Family Information: Parent 2

Emergency Informaton

Dental Insurance

Dental History

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