Patient Information | Kids Dental Experts

Name

First

Last

Date of Birth

Sex

Male
Female

Address

Address Line 1

City

State

Zip Code

Mailing Address (if different from above)

Address Line 1

City

State

Zip Code

Contact Info for Legal Guardian (if not bio parents)

How did you hear about us?

If Family/friend or Other please specify:

Preferred name:

Interests/hobbies

Please list other members of your immediate family who are patients at Kids Dental Experts

PARENT/GUARDIAN INFORMATION

Mother's Name

Date of Birth

Cell Phone

Address (if different than patient)

Address Line 1

City

State

Zip Code

Social Security Number

Employer & Position

Email

Work Phone

Father's Name

Date of Birth

Cell Phone

Address (if different than patient)

Address Line 1

City

State

Zip Code

Social Security Number

Employer & Position

Email

Work Phone

Biological Parents’ Marital Status

Address (if different than patient)

Address Line 1

City

State

Zip Code

Address (if different than patient)

Address Line 1

City

State

Zip Code

Patient Information Form

PARENT/GUARDIAN INFORMATION

MEDICAL HISTORY

Dental History

Only if the child is presently 18 months or younger, please complete the following:

I have completed the requested information on this form to the best of my knowledge.