Drs. Erin & Randy Elliott
Pediatric Dentistry

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 help keep their smile beautiful for their lifetime.

Your Child

Child's Name
Child's Home Address

Mother's Information


Are you responsible for account?

Father's Information


Are you responsible for account?


Parents Marital Status

Emergency Contact

Dental Insurance

Primary

Additional

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 ever had problems with
Allergies

Congenital birth defects

Congenital heart defects

Seizures

Recurrent/frequent headaches

Mental and physical developmental delays

Behavioral/learning problems

History of blood transfusions and date

History of abnormal bleeding/Hemophilia

Heart murmur

Kidney

Liver/GI system/Hepatitis

Diabetes/Thyroid disease

Breathing/Lung/Asthma

Blood disorders

Cancer/Tumors

Hearing

Sight

Frequent infections/Autoimmune

Significant injuries

HIV/AIDS

Social development (personality/temperament)

Hospitalizations

Dental History


Is your child's water fluoridated?
Does your child take fluoride supplements?
Does your child suck thumb/finger?
Does your child bite/chew nails?
Does your child grind teeth?
Pain in TMJ?
History of trauma to teeth?

Authorization and Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the periord of such dental care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.