:yB dellaC emaN :emaN lluF s’dlihC

:htriB fo ecalPMale Female :xeS :yadhtriB :egA

:enohP :sserddA emoH s’dlihC

City State Zip

Child’s Favorite Hobbies/Interests:

:eraC yaD/loohcS fo emaN

:)segA & semaN( sretsiS :)segA & semaN( srehtorB

:enohP :naicisyhP s’dlihC

Physician’s Address: Date of Last Exam:

:thgieW tnerruC s’dlihC

City State Zip

Child’s Current Height:

Parent/Guardian Name: Relationship to Patient:

Social Security Number: Date of Birth:

Employer: Work Phone:

Mobile Phone:

Parent/Guardian Name: Relationship to Patient:

Social Security Number: Date of Birth:

Employer: Work Phone:

Mobile Phone:

Email Address:

How did you find out about our office?

Emergency Contact/Friend or Relative Not Living with You

Name: Phone:

Address:

City State Zip

Insured’s Name: Relationship to Patient:

Insured’s Date of Birth: Insured’s Employer

Name of Insurance Co: Group Number:

I have received the following treatment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental plan benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or portion of such charges. To the extent permitted by law, I authorize release of any information relating to claims filed. I hereby authorize payment of the dental benefits otherwise payable to me directly to Bevin K. Malley, DDS, PA.

Signature of Insured:

Date:

Bevin K. Malley, DDS PABoard Certified Pediatric Dentist

5829 Phyliss Ln, Mint Hill, NC 28227ph: 704.790.0590 fx: 704.790.0593

email: info@ckdentistry.com www.ckdentistry.com

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Does your child currently have/previously had any of the following health problems?

Allergies (Food, Dust, Drug, Unknown) High/Low Blood Pressure :tsil esaelp ,sey fI

Any Current/Recent Injuries

Childhood Illnesses

Rheumatic Fever/Rheumatic Heart Disease Blood Transfusion

Congenital Heart Disease or Heart Murmur Any prolonged Bleeding/Bruises Easily

?dedeen demerp ,sey fI Kidney or Bladder Problems

:ycamrahP fo emaN Tuberculosis or Pneumonia

:rebmuN enohP ycamrahP Liver Problems, Jaundice or Hepatitis

Glandular or Hormonal Problems Accidents or Severe Infections

Diabetes/Blood Sugar Problems Psychological or Emotional Problems

Arthritis or Rheumatism (painful, swollen joints) Any Pending/Recent Surgery

Convulsions, Seizures, Fainting or Epilepsy Speech, Learning or Hearing Disorders

Anemia or Blood Disorders

reveF yaH ro amhtsA

(Please Indicate) If yes, please list any current medications:

?tnerruc snoitazinummi s’dlihc ruoy erA

Please explain any other medical concerns/current medication(s):

:rD yB :tisiv latned tsal fo etaD

?ecitcarp rehtona morf )syar-x gnidulcni( sdrocer tnerruc yna evah uoy oD

?smelborp latned yna tuoba denialpmoc dlihc ruoy saH

Any injuries or surgeries to the mouth, teeth, head? If yes, please describe:

?puc yppis ro elttob eht ekat llits dlihc ruoy seoD

?netfo woH yliad hsurb dlihc ruoy seoD

?desu ssolf latned sI

Please check if your child has any of the following habits:

Thumb Sucking Mouth Breathing Pacifier Nail Biting Finger Sucking Grinding Other:

How does your child receive fluoride? Water Supply Dentist Toothpaste Vitamins Tablets None Other:

Child’s attitude toward dentistry:

Reason for visit today/chief concerns:

I hereby certify that all of the above information is correct and true. Because the above-named child is a minor, it is necessary that a signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment can be commenced. Furthermore, I will be responsible for any professional fees incurred for dental services for my child. I understand that I am responsible for all charges whether or not covered by insurance. All balances over 30 days are subject to a 1.5% per month finance charge.

Signed:

Date:

:tneitaP ot pihsnoitaleR

Bevin K. Malley, DDS PABoard Certified Pediatric Dentist

5829 Phyliss Ln, Mint Hill, NC 28227ph: 704.790.0590 fx: 704.790.0593

email: info@ckdentistry.com www.ckdentistry.com

Do you assist your child with brushing? How often?

YES NO

YES NO

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YES NO

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YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO