Angelina Ring, DDS, Inc

Angelina Ring, DDS, Inc. Health History Form

Patient Information

______Gender: Male [ ] Female [ ] ____/____/______Child’s First Name Middle Last Birth Date

Purpose of visit: ______Concerns: ______Last dental visit: ______

Name and age of brothers and sisters: ______

Is your child adopted? Yes [ ] No [ ]

Child’s interests: ______Name of pet: ______

Does your child have any special needs?______

Child’s learning: Slow [ ] Average [ ] Accelerated [ ]

Child’s previous dentist: ______Family Dentist: ______

Orthodontist:______Who may we thank for referring you to us?______

Health History Reviewed: ______

Child’s Pediatrician: ______Date: ______Name Phone Last Physical

Is your child under a physicians care now? Yes [ ] No [ ] If Yes, Reason: ______

Pharmacy:______Name Address

Has your child received all immunizations? Yes [ ] No [ ]

Is your child taking medications or drugs? Yes [ ] No [ ] If Yes, What kind? ______Reason: ______

Has your child ever been hospitalized? Yes [ ] No [ ] If Yes, Reason: ______

Is your child allergic to any medications? Yes [ ] No [ ] If Yes, Please list: ______

Does your child have an allergic reaction to: [ ] eggs [ ] latex [ ] soy [ ] dust [ ] foods [ ] animals [ ] pollen [ ] other :______

Does your child have any of these habits: [ ] finger/thumb sucking [ ] pacifier [ ] lip sucking [ ] lip sucking [ ] snoring [ ] teeth grinding

Has your child had any injuries to teeth, mouth or head? Yes [ ] No [ ] If Yes, Describe: ______

Has your child had a history or difficulty with any of the following? Yes [ ] No [ ] Premature Birth Yes [ ] No [ ] Earaches Yes [ ] No [ ] Speech Disorder Yes [ ] No [ ]Nosebleeds Yes [ ] No [ ] Heart Yes [ ] No [ ] Kidney Yes [ ] No [ ] Hearing Yes [ ] No [ ] Asthma Yes [ ] No [ ] Seizures Yes [ ] No [ ] Bleeding Yes [ ] No [ ] Brain injury Yes [ ] No [ ] Liver Yes [ ] No [ ] Immune disorder Yes [ ] No [ ] Cerebral Palsy Yes [ ] No [ ] Bruising Yes [ ] No [ ] Brain Yes [ ] No [ ] Allergy to medication Yes [ ] No [ ] Anemia Yes [ ] No [ ] Bladder Yes [ ] No [ ] Rheumatic fever Yes [ ] No [ ] Diabetes Yes [ ] No [ ] Motion sickness Yes [ ] No [ ] Fainting or dizziness Yes [ ] No [ ] Tuberculosis Yes [ ] No [ ] Hepatitis Yes [ ] No [ ] Cancer Yes [ ] No [ ] Delayed Development Yes [ ] No [ ] Autism Yes [ ] No [ ] ADD/ ADHD Yes [ ] No [ ] Emotional or school problems Any medical condition not mentioned above:______

How may we help make this visit a positive experience for your child? ______

Notice of Privacy Practices I have received a copy of Napa Pediatric Dentistry’s Notice of Privacy Practices and Dental Materials Fact Sheet. You may refuse to sign this acknowledgement.

______

3425 Valle Verde Dr. Napa, CA 94558 | T: (707) 265-8389 | F: (707) 265-8444 | [email protected] | www.napapediatricdentistry.com

Signature Print Name Relationship to Patient Date

General Information

Parent 1 : ______-_____-______/____/______Full Name Social Security Number Phone Cell Birth Date

Parent 2: ______-_____-______/____/______Full Name Social Security Number Phone Cell Birth Date

Marital Status: Single [ ] Married [ ] Divorced [ ]

Child resides with: Both parents [ ] Parent 1 [ ] Parent 2 [ ]

Home address: ______Street City Zip Phone

Parent 1 employer: ______Employer Name (If self employed, please state business name) Phone Cell

Business address: ______Street City Zip Phone

Parent 2 employer: ______Employer Name (If self employed, please state business name) Phone Cell

Business address: ______Street City Zip Phone

Email address: ______Person financially responsible for child’s dental care: ______

Emergency contact 1:______Full Name Street City State Zip Phone

Emergency contact 2:______Full Name Street City State Zip Phone

The permission of parent or guardian is necessary for dental treatment of a minor. I give the dentist permission to use such measures as deemed necessary in his/her professional judgment to render the best dental treatment for my child. I understand, a late charge of 1.5% per month or a minimum late charge of $10.00 will be added to unpaid balances over 30 days past due and where appropriate, credit bureau reports may be obtained. Unpaid accounts are subject to collection costs.

______Signature Relationship Date

Insurance Information

Do you have dental insurance coverage for this child? Yes [ ] No [ ]

Parent 1 Insurance: ______Name of insurance company Group No.

Address of insurance company: ______Street City State Zip

Parent 2 Insurance: ______Name of insurance company Group No.

Address of insurance company: ______Street City State Zip

I hereby authorize payment to the above named dentist of the group dental benefits, otherwise payable to me but not to exceed the charges shown on the claim. I understand I am financially responsible for any charges not covered by my insurance by this authorization.

______Signature Relationship Date