Parent's Name: Phone (hm): Cell:

Address: City: Zip:

Email: Other Family Members:

First Dental Visit: Yes No ( If no, Dentist Name:
Are there current x-rays to be requested? Yes No )

Special Dental/Medical Concerns:

Emergency: Lost Filling Fractured tooth Toothache ( If toothache, how long? )
Bumped tooth Knocked out tooth On/Off Bleeding Constant Swelling Sensitive to hot/cold/sweet Other

Dental Insurance: Yes No or Other Coverage : Medicaid Headstart School Health
Children's Special Health Services

Parent informed that cost of first exam is expected at time of the visit to establish child as a patient

Parent informed we will be happy to file insurance and reimburse.