Muaraglia and Peck, DDS
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Child Registration

Welcome to our practice! We strive to make each of your child's visits pleasant and comfortable. Our goal is to teach your child oral habits which will he keep their smile beautiful for their lifetime. Please fill out this form to register children from the ages of 2 to 12 years old.
Email
 
Your Child
Child's name
Nickname
Sex


Birthdate:
Age:
Social Security number:
School:
Grade:
Address:
City:
State:
Zip:
Phone:
Parent's Marital Status:






Mother
Name:
Home phone:
Work phone:
Cell phone:
Social Security number:
Employer:
Occupation:
Drivers license number:
Legal standing:




Father
Name:
Home phone:
Work phone:
Cell phone:
Social Security number:
Employer:
Occupation:
Drivers license number:
Legal standing:




Responsible Party
Name:
Relationship:
Address:
City:
State:
Zip:
Social Security number:
Drivers license number:
Email:
Who is Responsible for Making Appointments?
Name:
Home phone:
Work phone:
Cell phone:
Best time(s) to call:
Primary Dental Insurance
Insured's name:
Relationship:
Birthdate:
Employer:
Date employed:
Occupation:
Insurance company:
Group number:
Employer number:
Insurance Company's Address:
Deductible:
Amount already used:
Maximum annual benefit:
Orthodontic coverage:
   
Additional Insurance
Insured's name:
Relationship:
Birthdate:
Employer:
Date employed:
Occupation:
Insurance company:
Group number:
Employer number:
Insurance Company's Address:
Deductible:
Amount already used:
Maximum annual benefit:
Orthodontic coverage:

Health History

Your child's overall health as well as any medications which your child takes could have an important interrelationship with the dental care your child receives. Please answer each of the following questions completely.

Has your child had difficulty with previous visits?
Does your child have a persistent cough or throat clearing not associated with a known illness?
   
 
Has your child ever taken Fen-Phen/Redux?
Has your child ever had any of the following?
   
Asthma
Cancer
Hepatitis
HIV/AIDS
Hemophilia
Diabetes
Allergies
   
 
   
Rheumatic Fever
Congenital Heart Defect
Handicaps/Disabilities
Convulsions/Epilepsy
Tuberculosis
Abnormal Bleeding
Heart Murmur
   
Please explain any medical problems that your child has:
Child's Habits
How often does your child brush?
How often does your child floss?
Date of last dental visit:
Previous dentist:
Child's physician:
Phone number:
Child's birthdate:
Is your child's water fluoridated?
 
Does your child take fluoride supplements?
Does your child:
Suck thumb/finger
Suck/bite lips
Bite/chew nails
 
Chew hard objects
Grind teeth
Clench jaws
 

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© 2010 Schmitz, Muraglia & Peck, DDS of Plainfield, IL
Plainfield Dentist

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