New Dental Patient Form

Child Registration Form - Dental

Patient Information


 




Parent / Guardian Information

Parents' Marital Status


Emergency Contact Information

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information




Dental History

How did you hear about our Practice?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply)?





Medical History

Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

How Did You hear About Us?

* How did you hear about us??


Location

* Which location would you like to submit this?


Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.



Security Measure

Lone Star Pediatric Dental & Braces

  • North Austin Office - 8716 Research Blvd., #125, Austin, TX 78758 Phone: (512) 454-4646 Fax: (512) 419-0561
  • Central Austin Office - 1015 W. 34th St., Austin, TX 78705 Phone: (512) 206-2929 Fax: (512) 206-2920
  • South Austin Office - 2700 S. 1st St., Austin, TX 78704 Phone: (512) 442-4338
  • Bee Cave Office - 14058 Bee Cave Pkwy. Building D, Suite B, Austin, TX 78738 Phone: (512) 402-9996 Fax: (512) 402-9986
  • Belton Office - 412 Lake Rd., Belton, TX 76513 Phone: (254) 933-7760 Fax: (254) 933-7983
  • Circle C Office - 5900 W. Slaughter Lane, Suite 470C, Austin, TX 78749 Phone: (512) 288-1900
  • Dripping Springs Office - 2440 E. Hwy. 290, Building C, Suite B, Dripping Springs, TX 78620 Phone: (512) 858-0232
  • Elgin Office - 250A Hwy. 290 W., Elgin, TX 78621 Phone: (512) 285-9868 Fax: (512) 933-7767
  • Killeen Office - 1103 W. Stan Schlueter Loop, Building B, Suite B-800, Killeen, TX 76549 Phone: (254) 519-1590 Fax: (254) 519-1570
  • Kyle Office - 575 E. Fm 150 Suite #P, Kyle, TX 78640 Phone: (512) 268-3600 Fax: (512) 268-3607

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