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(717) 267-1288
info@drakefamilydental.net
4202 Philadelphia Ave, Chambersburg, PA 17202
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Contact
Menu
Home
Our Doctor
Services
Cleaning
Exams
X-Rays
Fillings
Crowns & Bridges
Implant Services
Dentures
Partials
Extractions
Root Canals
Botox
Jeuveau
Contact
Home
Our Doctor
Services
Cleaning
Exams
X-Rays
Fillings
Crowns & Bridges
Implant Services
Dentures
Partials
Extractions
Root Canals
Botox
Jeuveau
Contact
Menu
Home
Our Doctor
Services
Cleaning
Exams
X-Rays
Fillings
Crowns & Bridges
Implant Services
Dentures
Partials
Extractions
Root Canals
Botox
Jeuveau
Contact
(717) 267-1288
info@drakefamilydental.net
4202 Philadelphia Ave, Chambersburg, PA 17202
Child Information Form
Step
1
of
2
50%
Your Child
Child's Name
First
Last
Nickname
Sex
Birthdate
MM slash DD slash YYYY
Age
SS# / SIN
School
Grade
Child's Home Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Responsible Party
Name
First
Last
Relationship
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Who is responsible for making appointments?
Name
First
Last
Best time to call
Home Phone
Cell Phone
Time
Days
Work Phone
Ext.
Mother
Mother
Stepmother
Guardian
Name
First
Last
Home Phone
Cell Phone
Work Phone
Ext.
Email
Employer
Occupation
Marital Status
Single
Married
Divorced
Widowed
Separated
Father
Mother
Stepfather
Guardian
Name
First
Last
Home Phone
Cell Phone
Work Phone
Ext.
Email
Employer
Occupation
Marital Status
Single
Married
Divorced
Widowed
Separated
Primary Insurance
Insured's Name
First
Last
Relationship
Date
MM slash DD slash YYYY
SS# / SIN
Employer
Date Employed
MM slash DD slash YYYY
Occupation
Insurance Company
Group #
Employee #
Insurance Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Financial Arrangements
For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment.
Preferred payment method
Cash
Personal Check
Credit Card
Visa
MC
I wish to discuss the office's payment policy
Dental and Health History
Your child's overall health as well as any medications which your child takes could have an important inter-relationship with the dental care your child receives. Please answer each of the following questions completely.
How often does your child brush?
How often does your child floss?
Is your child's water fluoridated?
Yes
No
Does your child take fluoride supplements?
Yes
No
Does your child:
Suck thumb / finger
Yes
No
Chew hard objects (pencils, etc.)
Yes
No
Suck/Bite lip
Yes
No
Grind teeth
Yes
No
Bite/Chew nails
Yes
No
Clench jaws
Yes
No
Previous Dentist
Address
Date of Last Dental Visit
MM slash DD slash YYYY
Has your child had difficulty with previous dental visits?
Yes
No
Child's Physician
Address
Phone
Previous hospitalizations / surgeries / serious illnesses?
When?
Is your child currently taking medication?
Yes
No
Please list:
Does your child have a history of allergies / sensitivities / adverse reactions to any drugs or medications (Penicillin, Novocain, etc.)?
Yes
No
Please Describe:
Does your child have a history of allergies to any other substances (latex, environmental, etc.)?
Yes
No
Please list:
Has your child had any of the following?
Acid Reflux?
Yes
No
Heart Problems
Yes
No
Anemia
Yes
No
Describe:
Asthma
Yes
No
Hemophilia (abnormal bleeding)
Yes
No
Blood Transfusion
Yes
No
Hepatitis
Yes
No
Cancer
Yes
No
HIV / AIDS
Yes
No
Convulsions / Epilepsy
Yes
No
Persistent Cough
Yes
No
Diabetes
Yes
No
Rheumatic Fever
Yes
No
Handicaps / Disabilities
Yes
No
Stomach, liver, or kidney problems
Yes
No
Hearing Impairment
Yes
No
Tuberculosis
Yes
No
Please explain any medical problems that your child has:
Authorization & Release
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services my child may need.
I also authorize the Dentist to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the Dentist or Dentist's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. i agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of patient (or parent / guardian if minor)
Date
MM slash DD slash YYYY