10717 Camino Ruiz, Suite 103
San Diego, CA 92126
858.536.1111

Children's Dentistry of San Diego - New Patient Form

Welcome!

We are pleased to welcome you to our practice.
Please take a few minutes to fill out this form completely.
Don’t hesitate to call and ask us if you have any questions.
Our goal is to make you and your child’s dental experience "A Walk In The Park!"
We care about you and your dental experience here at Children's Dentistry of San Diego.
Your privacy is highly respected and your information is strictly confidential.
This online form is secure.

Patient Information

CONFIDENTIAL PATIENT INFORMATION
*Patient First Name
Middle
*Last Name
Gender
M
F
Birth date (mm/dd/yyyy)
Patient Social Security#
Child Prefers To Be Called
Street Address
City
State
Zip
Home Phone
CONFIDENTIAL RESPONSIBLE PARTY INFORMATION
Parent Guardian 1 Information
Parent/Guardian 1
Mr.
Mrs.
Miss
Ms.
First Name
Middle
Last Name
Marital Status
Single
Married
Divorced
Separated
Other
Home Phone
Work Phone
Cell Phone
Birth date (mm/dd/yyyy)
Relationship to patient
Same Address as Patient?
Yes
Street Address
PO Box
City
State
Zip
Email
Social Security #
Occupation
Employer
Employer Address
Employer Phone #
Parent Guardian 2 Information
Parent/Guardian 2
Mr.
Mrs.
Miss
Ms.
First Name
Middle
Last Name
Marital Status
Single
Married
Divorced
Separated
Other
Home Phone
Work Phone
Cell Phone
Birth date (mm/dd/yyyy)
Relationship to patient
Same Address as Patient?
Yes
Street Address
PO Box
City
State
Zip
Email
Social Security #
Occupation
Employer
Employer Address
Employer Phone #
CONFIDENTIAL INSURANCE INFORMATION
Is this patient covered by insurance
Yes
No
If yes, does patient have dual coverage?
Yes
No
Name of primary insurance
Insurance Company Address
Insurance Co. Phone
Subscriber’s name
Subscriber’s ID/SSN
Birth Date (mm/dd/yyyy)
Group #
Policy #
Co-payment $
Patient’s relationship to subscriber
Child
Other
Name of secondary insurance (if applicable)
Insurance Company Address
Insurance Co. Phone
Subscriber’s name
Subscriber’s ID/SSN
Birth Date (mm/dd/yyyy)
Group #
Policy #
Co-payment $
Patient’s relationship to subscriber
Child
Other
REFERRAL INFORMATION
Who can we thank for referring you to our office?
(please check all applicable boxes if more than one source)
(check all that apply)
Referred by another office (Enter name into box)
Insurance Plan
Hospital
Friend (Enter name into box)
Family (Enter name into box)
Location (Enter name into box)
Advertisement (Enter name into box)
Enter Name of Referring Person or Advertisement or Office
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address)
Relationship to patient
Home phone #
Work phone #
EMAIL CONSENT
Please select one. I understand I can change my consent at any time
I consent and accept the risk in receiving information via email. I consent to receiving appointment reminders via email or text.
I do not consent to receiving any information via email.

Patient Health History

PATIENT HEALTH HISTORY
Child’s Physician
Physician’s Phone
Physician’s address
Date of last physical exam (mm/dd/yyyy)
Results
Is child under care of physician now?
Yes
No
If yes, why?
Receiving any medications or drugs?
Yes
No
If yes, why?
Ever been hospitalized?
Yes
No
If yes, why?
Ever had surgery?
Yes
No
If yes, why?
Medical History
Check all that apply
A.I.D.S./H.I.V.
Anemia
Bladder Problems
Blood Transfusion
Bruise Easily
Cancer
Skeletal problems
Cerebral Palsy
Cleft Lip/Palate
Convulsions
Developmental Disability
Diabetes
Epilepsy
Fainting
Hay Fever
Hearing Problems
Heart Problems
Hepatitis
Jaundice
Kidney Disease
Liver Disease
Mental Disability
Rheumatic Fever
Sinus Problems
Thyroid Disease
Tuberculosis
Premature
Other (Please specify below)
If Other, Please Specify
Any medications taken?
Has child ever had any asthmatic attacks?
Yes
No
If yes
Mild
Moderate
Severe
Frequency?
Comments
Is child allergic to, or ever had an adverse reaction to the following?
Check all that apply
Penicillin
Amoxicillin
Local Anesthetics
Sedatives
General Anesthesia
Sulfa Drugs
Latex
Other Allergies (please list)
Dental History
Is this your child's first dental visit?
Yes
No
If No, Previous Dentist Name
Phone #
Date of last visit (mm/dd/yyyy)
Services Received
Please check all that apply to your child.
Has had trouble associated with a previous dental treatment
I have been satisfied with my child’s previous dental care
Brushes daily
Flosses daily
Gums bleed while brushing or flossing
Bites lips, cheeks, or nails
Sensitivity to hot/cold, sweet/sour
Takes flouride in any form
Sucks his/her thumb
Uses a pacifier or bottle
Has had orthodontic work
Experiences pain in any teeth