New Patient Information (child) Name First Middle Last Nickname Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Sex Male Female Phone (residential)Phone (cell)Are other members of your family patients here? Yes No Names How did you hear about us? Which Doctor do you prefer to see?No PreferenceJames O. OlsonJustin J. McHughKyle WilkensJanis KlecherBrian ShraggGregory J. KemmittMothers Name Mothers SSNMother's Employer's Name Mother's Employer's Phone Number Fathers Name Fathers SSNFather's Employer's Name Father's Employer's PhoneWith whom does the child reside? Who do we contact in case of emergency? Emergency Contact PhoneRelationship to Patient Do you have dental insurance?* Yes No If yes, we will need a copy of your card and our green insurance form filled out Because your child is a minor, it is necessary that signed permission be obtained from a responsible party before any necessary dental treatment is performed. The signature below authorizes the completion of all agreed upon dental treatments and the use of those methods appropriate thereto. This consent shall remain in force and effective until cancelled by either party. Furthermore, this signee will be responsible for any bill incurred during this child's treatment. A 1.5% monthly interest charge will be added to unpaid balances over 90 days. To the best of my knowledge, all information on this form is correct.Responsible Party Name Relationship to Patient Signature of responsible party:Date MM slash DD slash YYYY Dental HistoryDo you have any dental concerns you would like addressed?NoYesIf yes, what are they? Former Dentist Name Address Phone Date of last visit MM slash DD slash YYYY Approximate date of last x-ray MM slash DD slash YYYY How often does your child brush? How often does your child floss? Has your child ever experienced a mouth or chin injury?NoYesIf yes, please describe Does your child have speech problems?NoYesIf yes, please describe Has your child ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?NoYesIf yes, please describe Is there any other information about your child's dental health or previous treatment we should know about?Medical HistoryChilds Physician First Last PhoneHas your child had any serious illnesses or operations?NoYesIf yes, please describe Is your child currently under the care of a physician?NoYesIf yes, please describe Heart Murmur Heart valve dysfunction Prosthetic device (hip or joint repl. pins, plates) Rheumatic fever Need to be premeditated due to medical condition Abnormal blood pressure Blood transfusion Hemophilia/ blood disorder Anemia Prolonged bleeding Positive to HIV Hearing problems ulcer Epilepsy Arthritis Asthma Glaucoma Sinus problem Stroke Thyroid disorder Tuberculosis Novocaine allergy Drug allergy Other allergy Circulatory Problems Emphysema Diabetes Hepatitis Tobacco use Smoking Alcohol/drug dependency Psychiatric care Cancer Radiation Theropy Demensia Currently Pregnant Other physical conditions:The above medical/dental history is complete and accurate:Date MM slash DD slash YYYY Consent to Text Messaging I allow Blue Ridge Dental to contact me through text messages.
