Commerce Park Children's Dentistry & Orthodontics

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Pediatric Registration Form

If you do not wish to submit this form online, you can download a printable form (requires Adobe Acrobat®).

Patient Information

Last Name
First Name
Middle Initial
Sex
Prefers to be addressed by
Date of Birth	/ /
Age (years)
Address
Apt. #
City
State
Zip
Home Telephone
Cell Phone#
Other family members treated at this office

Parental Information

Mother
Name
Date of Birth	/ /
Social Security #
E-mail Address
Single Married Widowed Separated Divorced Guardian
Employer
Employer Address
Employer Telephone

Complete if different from patient's home information:
Home Address
City
State
Zip
Home Telephone


Father
Name
Date of Birth	/ /
Social Security #
E-mail Address
Single Married Widowed Separated Divorced Guardian
Employer
Employer Address
Employer Telephone

Complete if different from patient's home information:
Home Address
City
State
Zip
Home Telephone

Dental Insurance Information

Primary Insurance
Company
Address
City
State
Zip
Insurance Telephone
Policy / Group #
Policy Holder's Name
Relationship to Patient


Secondary Insurance
Company
Address
City
State
Zip
Insurance Telephone
Policy / Group #
Policy Holder's Name
Relationship to Patient

Referral Information

How did you hear about us?
Name of person to thank for referral

DENTAL HISTORY

Previous dentist (If any)
Date of last dental exam
When, if ever, were x-rays taken? Where?
What concerns you most about your child's dental health?
Does your child ever have dental pain? If so, where?
Is your child developing mentally and socially as his/her age would indicate?
Mouth habits (Please check): Thumb Sucking Pacifier Mouth breathing Still on bottle Finger habit Tooth grinding None
Did your child ever have a negative dental experience? Discuss
Has the child had teeth removed?
How often does your child brush? Floss?
Has the child received any fluoride treatment? Amount
Do you have: Well Water? City Water?
Has your child received fluoride supplements? Yes No
Are they still receiving fluoride supplements? Yes No
Are you happy with the appearance of your child's teeth?
Has your child or any family member had a history of temporal mandibular joint disorder (TMJ)? If so, describe

MEDICAL HISTORY

Is the patient's general health good at this time?
Yes No

Name of physician?
Date of last physical:

Is the patient under the care of a physician at this time?
Yes No
Explain:

Is the patient taking any medication?
Yes No
If yes, what:

Is the patient allergic to any medication? (Penicillin, Sulfa, etc.)
Yes No
If yes, what:

Does the patient have any other allergies (metals, latex, seasonal etc.)
Yes No
If yes, what:

Has the patient had tonsils and adenoids removed?
Yes No
Date:

Has the patient ever had a serious illness or been hospitalized?
Yes No
Date:
Explain:

Has the patient ever been advised by their physician to take an antibiotic prior to any dental treatments?
Yes No
If yes, antibiotic name and method:

Has the patient reached puberty?
Yes No

Is there any other information that should be known about your child's health?

Does the patient have now or have they ever had any of the following?

Birth Defects	Yes No
Hearing/Sight Impaired	Yes No
Endocarditis	Yes No
Heart Condition	Yes No
Heart Pacemaker	Yes No
Mitral Valve Prolapse	Yes No
Congenital Heart Disease	Yes No
Artificial Heart Valve	Yes No
Heart Surgery date:	Yes No
Heart Murmur	Yes No
Rheumatic Fever	Yes No
Prosthetic (artificial) Joint	Yes No
X-Ray/Radiation (cancer) Therapy	Yes No
AIDS or H.I.V. Positive	Yes No
Diabetes	Yes No
Respiratory Lung Disease	Yes No
Hepatitis (type? )	Yes No
Tuberculosis	Yes No
Developmental Delayed	Yes No
Learning Delayed	Yes No
ADD	Yes No
Blood Disorders/Bleeding Problems	Yes No
Blood Transfusions	Yes No
Sickle Cell	Yes No
Arthritis	Yes No
Ulcers	Yes No
Anemia	Yes No
Asthma	Yes No
Epilepsy (seizures)	Yes No
Fainting Spells	Yes No
Kidney Trouble	Yes No
Liver Disease	Yes No
Psychiatric Treatment	Yes No
Headaches	Yes No
Earaches	Yes No
Jaw Clicking	Yes No
Allergies	Yes No
Jaw Pain	Yes No
Tonsillitis	Yes No
Emotional Problems	Yes No
Other:	Yes No

If you submit this form online, you will have a preprinted form ready for your signature at the time of your appointment.

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Members of the American Academy of Pedicatric Dentistry
Commerce Park Children's Dentistry & Orthodontics Members American Association of Orthodontics
Bridgeport • 4702 Main Street • (203) 371-8282 | Huntington • 27 Huntington Plaza • (203) 926-9929

Pediatric Dentistry and Orthodontics for the Infants, Children and Teens of Ansonia, Beacons Falls, Bridgeport, Cos Cob, Darien, Derby, East Haven, Easton, Fairfield, Hamden, Milford, Monroe, New Canaan, New Haven, Newtown, Norwalk, Orange, Oxford, Redding, Ridgefield, Rocky Hill, Rowayton, Saugatuck, Seymour, Shelton, Southbury, Stratford, Trumbull, West Haven, Weston, Westport, Wilton and Woodbridge, Connecticut.
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