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3919 Creekside Loop • Yakima • WA • 98901 • (509) 968-5608

Patient Information

CHILD'S FULL NAME

Preferred Name

School

Birthdate / Age

Sex

Male Female

Father's Information

Stepfather Guardian

FATHER'S NAME

Birthdate / Social Security No.

Mailing Address

City / State / Zip

Home Phone

Employer / Work Phone

Cell Phone / Best Contact#

Marital Status

Married Single Divorced Separated Widowed

Mother's Information

Stepmother Guardian

MOTHER'S NAME

Birthdate / Social Security No.

Mailing Address

City / State / Zip

Home Phone

Employer / Work Phone

Cell Phone / Best Contact#

Marital Status

Married Single Divorced Separated Widowed

With whom does this child reside?

Email Address

INSURANCE COVERAGE (We must bill private insurance prior to Medicaid)

#1.

Subscriber Name

#2.

Subscriber Name

MEDICAID ID#

By signing I acknowledge I have listed all Insurance above. I also authorize littleBIGkids Pediatric Dentistry to receive direct payment of benefits from my insurance.

Signature

Click to Sign

Date:-------------

No dental insurance

Person financially responsible for child's account

IN CASE OF EMERGENCY, OTHER THAN THOSE LISTED ABOVE WHOM MAY WE CONTACT

Name

Home Phone / Work Phone

Relationship to Patient

MEDICAL HISTORY

Please answer all questions, so that we may diagnose your child's oral health as accurately as possible. All information will be kept strictly confidential. Thank you.

Is your child presently under the care of a physician?

Yes No

Child's Physician

Office Name / Phone

Date of last physical exam / Findings

Former Dentist

Office Name / Phone

Is your child:

In good health?

Yes No

Sensitive or allergic to any medications or latex?

Yes No

Taking any medications?

Yes No

Has your child ever had any surgeries?

Yes No

Does your child have any other Problems, Conditions Or Special Needs?

Conclusion

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 strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize littleBIGkids Pediatric Dentistry doctors and/or dental staff to perform the necessary dental services my child may need. This may include exams, radiographs, cleanings, topical fluoride treatment, restorative dentistry, oral surgery or limited orthodontics. In order to perform such treatment, our team may recommend the use

Parent/Guardian Signature

Click to Sign

Date:-------------

truForm by PBHS

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Demographic Information

Patient Information

Father's Information

Mother's Information

Insurance Information

INSURANCE COVERAGE (We must bill private insurance prior to Medicaid)

Click to Sign

IN CASE OF EMERGENCY, OTHER THAN THOSE LISTED ABOVE WHOM MAY WE CONTACT

How did you hear about our office?

How did you hear about our office?

Medical History

MEDICAL HISTORY

Is your child:

Does your child have any history of the following conditions (please check):

Medical History Continued

Conclusion

Conclusion

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Main Header

Demographic Information

Patient Information

Father's Information

Mother's Information

Insurance Information

INSURANCE COVERAGE (We must bill private insurance prior to Medicaid)

Click to Sign

IN CASE OF EMERGENCY, OTHER THAN THOSE LISTED ABOVE WHOM MAY WE CONTACT

How did you hear about our office?

How did you hear about our office?

Medical History

MEDICAL HISTORY

Is your child:

Does your child have any history of the following conditions (please check):

Medical History Continued

Conclusion

Conclusion

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.