Patient Registration

Dental Insurance Company Name: (if none N/A)

Child's Primary Physician and Office Phone Number:

Are you child's immunizations up to date?

If no, please explain:

Has your child ever been hospitalized or had a surgery?

If yes, please explain:

Is your child taking any prescription or over-the-counter medications?

If yes, please list:

Does your child have a medical condition that requires medication prior to dental treatment?

If yes, please explain:

Does your child have any drugs allergies?

If yes, please list:

Does your child have any other non drug allergies (foods, seasonal allergies, etc.)?

If yes, please list:

Has your child ever had any of the following conditions? (you must hold down shift to make multiple selections)

Please give more details (date, outcome) of any checked items:

Were there any complications or problems during pregnancy or delivery?

If yes, please explain:

Is there anything else you would like us to be aware of?

If yes, please explain:

Digital Signature

I understand that the information I have given 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.

PATIENT REGISTRATION

Hours

Meredith Kurysh, DDS