New Patient Paperwork - Bridger Children's Dentistry

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About
Our Specialties
Resources
- Financing & Insurance
- Patient Education
Forms
Referrals

New Patient Form

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- Step 1 of 6

Tell Us About Your Child

How did you hear about our practice?

Child's First & Last Name *

First

Last

Nickname

Patients Gender

Male
Female

Patients Birthdate *

Child's Age

Child's Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's School

Special Interests

Siblings We Treat

Child's Home Phone *

Child's 1st Language

Child's 2nd Language

Dental History

Is this your child's 1st visit to the dentist?

Yes
No

If this is not their first visit, how long has it been since their last trip to the dentist?

Date of last X-rays 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 your child currently have or had in the past, any of the following habits?

Lip Sucking/Biting
Nail Biting
Nursing/Bottle Habits
Pacifier
Thumb Sucking/Finger Sucking
Tobacco Use
Tongue Thrust

Does your child have any current dental issues?

Airway Evaluation
Bad Breath
Bleeding Gums
Cavities
Chronic Congestion
Discolored Teeth
Mouth Breathing
Mouth Trauma
Orthodontics
Sensitivity to Hot or Cold Teeth Grinding
Toothache

Is your child's water fluoridated?

Yes
No

Is your child taking a fluoride supplement?

Yes
No

Has your child ever had any pain in the jaw joint (TMJ/TMD)?

Yes
No

How often does your child brush his/her teeth?

Does your child use fluoridated toothpaste?

Yes
No

How often does your child floss?

your Layout child

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

Yes
No

If yes, please explain:

Birth History

Pregnancy

Full Term
Premature

If premature, by how many weeks?

Delivery

Vaginal
Cesarean

Complications with delivery:

Complications with delivery:

Yes
No

Duration/age weaned

Baby led weaning?

Yes
No

Difficulties Breastfeeding:

Painful Latch
Frequent Feedings
Reflux
Colic
Low Supply
Clicking

Medical History

Has your child ever had any of the following conditions? *

Abnormal Bleeding
ADD/ADHD
Allergies to Any Drug
Allergies to Latex Products
Any Hospital Stays
Any Surgeries
Asthma
Cancer
Cardiac (Heart Condition)
Autism Spectrum Disorder
Congenital Birth Defects
Diabetes
Down Syndrrome
Hearing Impairment
Hepatitis
Developmental Delays/Disabilities
HIV/AIDS
Hemophilia/Blood Disorder
Pregnancy
Reflux/GI Problems
Kidney/Liver Condition
Rheumatic/Scarlet Fever
Tuberculosis
None of the Above

If you have checked any of the above conditions or if you would like to discuss any other medical conditions your child has had, please explain below:

List all drugs/supplements your child is currently taking: N/A if not applicable* *

List all allergies your child currently has: N/A if not applicable* *

Please describe your child's current physical health

Good
Fair
Poor

Does your child require antibiotics for dental procedures?

Yes
No

Is your child currently under the care of a physician?

Yes
No

Child's Physician:

Parent or Legal Guardian's Information/Person Responsible for Account

Parent First & Last Name *

First

Last

Marital Status *

Single
Married
Divorced
Widow

Parent Date of Birth *

Relationship to Patient *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Position

SSN

Work Phone

Cell Phone *

Email

Additional Guardian's Information/Person Responsible for Account

First & Last Name

First

Last

Marital Status

Single
Married
Divorced
Widow

Date of Birth

Relationship to Patient

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Position

SSN

Work Phone

Cell Phone

Email

Non-Legal Guardian Accompanying Your Child/Children to Their Appointment?

Important Note: The parent or legal guardian is required to provide consent for dental treatment. The adult who accompanies the child is responsible for payment at the time of service. To ensure your child/children’s safety, please provide non-legal guardian information below.

First & Last Name

First

Last

Relationship to Patient

Do you have legal custody of this child?

Yes
No

First & Last Name

First

Last

Relationship to Patient

Do you have legal custody of this child?

Yes
No

Primary Dental Insurance

Insurance Name

Insurance Phone Number

Insurance Address

Address Line 1

Address Line 2

City

State

Zip Code

Subscriber Number

Group Number

Policy Owner's Name

Relationship to Patient

Subscriber Birthdate

SSN

Employer

Secondary Insurance

Do you have dual coverage?

Yes
No

Insurance Name

*

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

Responsible Party's First & Last Name *

First

Last

Today's Date *

1039 Stoneridge Drive, Suite 1, Bozeman, MT 59718

Phone: (406) 587-KIDS (5437)

Fax: (406) 577-2172

info@BridgerChildrensDentistry.com

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About
Our Specialties
Resources
- Financing & Insurance
- Patient Education
Forms
Referrals

Hours

Monday

8 AM – 5 PM

Tuesday

8 AM – 5 PM

Wednesday

8 AM – 5 PM

Thursday

8 AM – 5 PM

Friday

8 AM – 2 PM

Saturday

Closed

Sunday

Closed

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