Child Registration - Cottonwood Dental Care

Patient Information

Gender

MaleFemale

First Name

Last Name

Social Security Number

School

Birth Date

Who should we contact in an emergency?

Parent or Guardian Emaila valid email

Mother's Information

Mother's Name

Mother's Birth Date

Mailing Address

City

Zip Code

Phone

Drivers Licenseyour full name

Social Security Number

Mother Employed By

Positionyour full name

Employer Address

Father's Information

Father's Name

Father's Birth Date

Mailing Addressyour full name

City

Zip Code

Phone

SSN

Drivers Licenseyour full name

Father Employed By

Positionyour full name

Employer Address

Insurance Information

Present your insurance card at the front desk when you arrive.

Insurance Provideryour full name

Insurance Provider Address

Policy #

Group #

Policy Holder's Name

Birthdateof appointment

Medicaid #

County

PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. I understand that I am financially responsible for all charges on date of service whether or not paid by insurance. I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits.

I Agree

Payment Not Covered by Insurance Will be Made With

CheckCashCredit CardCare Credit

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

Download, view or print this office's Notice of Privacy practices by clicking here.

I have received a copy of this office’s Notice of Privacy Practices.

Full Nameyour full name

Dateof appointment

Dental History

Do You Have a Dental Exam on a Regular Basis?

YesNo

Last Visitof appointment

Do Your Gums Bleed

YesNo

Discuss

If you could change anything about your teeth or smile, what would you change?

0 /

What would you like your teeth to be like in 20 years?

0 /

Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind?

YesNo

Have your past experiences in a dental office always been positive?

YesNo

Do you smoke or chew, or have any sores or growths in your mouth?

YesNo

Name of Previous Dentist

Date of last mouth x-rays

Medical History

Do you presently have any conditions our staff should be aware of?

YesNo

Please describe the conditions

0 /

Have you ever been hospitalized or had a major operation?

YesNo

Please provide details of hospitalization or operation

0 /

Are you under a physician’s care now?

YesNo

Please provide physicians name and additional information about treatment.

0 /

Have you ever had a serious injury to your head or neck?

YesNo

Please provide information about the injury.

0 /

Are you taking any medication, pills or drugs?

YesNo

Please provide information about the medication or drugs.

0 /

Are you on a special diet?

YesNo

Please provide details about the diet.

0 /

List Allergies

Conditions

Please contact our office prior to you appointment. Premedication may be required

Have you ever had any other serious illness not checked above?

YesNo

Please describe the illness.

0 /

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.

Yes