New Patient Form - Styled - Jungle Dental | Pediatric Dentistry

561-395-5081

About Us
Jungle Smile Club

Jungle Dental | Pediatric Dentistry - Boca Raton, Florida

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About Us
- Meet the Doc
- Our Services
Office Tour
Patient Info
- Jungle Smile Club
Contact Us
- Request an Appointment

561-395-5081

Home
About Us
- Meet the Doc
- Our Services
Office Tour
Patient Info
- Jungle Smile Club
Contact Us
- Request an Appointment

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Siblings We Treat

Child's Birthdate *

Child's Age

Child's Home Number

Child's Home Address *

Address Line 1

City

State

Zip Code

2. Mother's Information

Name *

Relationship to Child *

Birthdate *

Mother's Home Address *

Address Line 1

City

State

Zip Code

Employer

Work Number

Home Number

Cell Number *

Email Address *

3. Father's Information

Name

Relationship to Child

Birthdate

Father's Home Address

Address Line 1

City

State

Zip Code

Employer

Work Number

Home Number

Cell Number

Email Address

4. Who May We Thank For Referring You?

Name

5. Who Is Accompanying Your Child Today?

Name *

Relationship *

Do you have legal custody of this child? *

Yes
No

6. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

7. Secondary Dental Insurance

Insurance Company Name

Insurance Co. Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

8. Dental History

Is this your child's first visit to the dentist? *

Yes
No

If not, how long since the last visit to the dentist?

Previous Dentist's Name

Were any x-rays taken at previous dental visits?

Have there been any injuries to the teeth, face or mouth? *

Yes
No

If yes, please explain:

Why did you bring your child to the dentist today?

Does the child have any of the following habits?

Lip Sucking / Biting: *

Yes
No

Nail Biting: *

Yes
No

Nursing / Bottle Habits: *

Yes
No

Thumb / Finger Sucking: *

Yes
No

Has the child ever had a serious or difficult problem associated with previous dental work? *

Yes
No

If yes, please explain:

Is this child's water fluoridated?

Yes
No

Does the child brush his/her teeth daily?

Yes
No

Is the child taking fluoride supplements?

Yes
No

Floss his/her teeth daily?

Yes
No

Has the child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?

Yes
No

9. Health History

Has the child ever had any of the following conditions?

Abnormal Bleeding *

Yes
No

Handicaps/Disabilities *

Yes
No

Congenital Birth Defects *

Yes
No

Rheumatic/Scarlet Fever *

Yes
No

Allergies to Any Drugs *

Yes
No

Hearing Impairment *

Yes
No

Convulsions/Epilepsy *

Yes
No

Allergies to Latex Product *

Yes
No

Any Hospital Stays *

Yes
No

Heart Disease/Murmur *

Yes
No

Pregnancy *

Yes
No

Diabetes *

Yes
No

Any Operations *

Yes
No

Hepatitis *

Yes
No

Tuberculosis *

Yes
No

Hemophilia/Blood Disorders *

Yes
No

Asthma *

Yes
No

HIV + / AIDS *

Yes
No

ADD/ADHD *

Yes
No

Reflux/GI Problems *

Yes
No

Cancer *

Yes
No

Kidney/Liver Conditions *

Yes
No

Please discuss any serious medication conditions the child has had: (or write NONE) *

Please list all the drugs the child is currently taking: (or write NONE) *

Please list all drugs the child is allergic to: (or write NONE) *

Child's Physician *

Phone Number

Is this child currently under the care of a physician? *

Yes
No

Please describe the child's current physical health *

Good
Fair
Poor

10. Signature

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Authorization *

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature (First & Last Name) *

Date *

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