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Child Form

Farrar Family Dentistry / Patient / Patient Forms / Child Form

Child Form

Patient Forms

Child Form

Office Hours

Monday 8:00 a.m. - 2:00 p.m.
Tuesday 9:00 a.m. - 6:00 p.m.
Wednesday Closed
Thursday 8:00 a.m. - 5:00 p.m.
Friday 8:00 a.m. - 5:00 p.m.
Saturday By Appointment
Sunday Closed

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

School:

Grade:

List any sports or extracurricular activities:

Siblings (names and ages):

Parent / Guardian Information

Parent 1

Name:

Marital Status: Single Married Divorced Widowed Significant Other

Relation to Child: Mother Step-Mother Guardian Other

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Parent 2

Name:

Marital Status: Single Married Divorced Widowed Significant Other

Relation to Child: Father Step-Father Guardian Other

Address (if different than child's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name (other than parent):

Phone Number:

Relation to Child:

Address:

City:

State:

Zip:

Person(s) you allow us to release appointment or medically-related information regarding your child to:

Relation(s) to Child:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

How did you hear about our practice? Ad Internet Family/Friend Physician Other

Name of person referring (if applicable):

Have we treated any other family members? Yes No

Name:

Have your child's tonsils or adenoids been removed? Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Does your child have any missing or extra permanent teeth? Yes No

Has your child ever had an injury to (select all that apply): Teeth Mouth Chin

Does your child have speech problems? Yes No

If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

Medical History

Is your child currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Does your child have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Is your child currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Has your child had any serious illnesses or operations? If yes, describe:

Check if your child has or has ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal Disease

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date:

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Locations

Farrar Family Dentistry7010 NC Hwy. 751 Suite 103Durham, NC 27707919.973.5696 Get Directions

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Farrar Family Dentistry

Let us help you! We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us.

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