Dover Kids Teeth

Yes

Has your dental insurance changed? *

Name of Insured *

Relationship to Patient *

please elaborate *

Date of Birth *

Name of Employer

Dental Insurance Company *

Group #

Policy/ID # *

Insurance Address

City

State

Zip Code

Insurance Phone #

Insurance Card FRONT File Format: JPEG, PDF and PNG. Max. Size: 10 MB

Insurance Card BACK File Format: JPEG, PDF and PNG. Max. Size: 10 MB

Date of Change

Yes	No	Has your child ever had difficulty receiving dental care? *
If yes, please explain *
Yes	No	Has your child’s teeth ever been injured? *
If yes, please explain *

Yes	No	Is your child currently taking / has your child previously taken a prescription fluoride supplement? *
Yes	No	Does/did your child have any sucking habits (i.e. thumb sucking, pacifier)? *
If yes, please explain *
Yes	No	Does/did your child have a tongue or lip tie? *
If yes, was a frenectomy advised or performed? Yes No When? *
Yes	No	Does your child go to bed with a bottle or sippy cup? *
If yes, what is the liquid? *
Yes	No	Does your child have a family history of congenitally missing teeth? *

Yes	No		Do you have Primary Care Physician? *
Patient’s Primary Care Physician Date of last exam
Reason *
Yes	No		Are your child’s immunizations up to date? *
Explain:
Yes	No		Is your child presently being treated for any condition? *
If yes, what condition and who is the specialist? *
Yes	No		Is your child receiving any medications or drugs? *
If yes, what are the medications and for what reason? *
Yes	No	Don't know	Has your child ever been hospitalized or had surgery? *
If yes, please explain: *
Yes	No		Does your child have any allergies to food, medications or other? *
List All: *
Yes	No		Does your child have a heart condition / murmur? *
If yes, is it due to a congential heart condition that requires antibiotics before dental procedures? *

Monday - Thursday	8:00 AM – 5:00 PM
Friday - Sunday	Closed