JA Reynolds DDS

Child's Dental History Form

We are dedicated to the concept that all people have the opportunity to retain their teeth throughout their lifetime with optimum health, function, comfort and esthetics. We realize the importance of your smile and are committed to offering the best that dentistry has to offer — providing quality restorative dentistry with special emphasis on cosmetics. Thanks for coming.

Patient Information (for children under 18)
Child's Last Name	Child's First Name
Gender: Female Male
Date of Birth:	Social Security #:
E-mail Address:
Street Address:
City:	State:	Zip:
Home Phone:	Business Phone
Other family who use our services:	Who referred you?
In Case Emergency
Closest friend or relative (not living with you):
Home Phone:	Daytime Phone:
Spouse’s Name:	Spouse’s Occupation:
Daytime Phone:	Business Phone:
Business Address:
Insurance Information
Name of Subscriber (Name insurance is listed in.):
Subscriber’s Birth Date:	Subscriber I.D.#:
Group/Policy#:
Subscriber’s Street Address:
Subscriber’s Employer:
Patient’s relationship to insured: Self Spouse Child Other
Insurance Plan Name:
Delta Dental Policy: Dr. Reynolds is considered an “out-of-network” provider with ALL insurance companies due to our “out-of-network” status, Delta Dental has informed us all re-imbursements will be sent to the subscriber. This means your insurance company will mail payments directly to you. In order to simplify the filing process we ask that you provide us with your dental insurance information. This will give us the ability to print a claim and you (the patient) are not required to fill out any extra forms. To receive your re-imbursement you will simply mail the insurance claim form to the insurance company. They will process your claim and send payment to you. NOTE: Patients using Delta Dental insurance are required to pay in full at the time of their visit.
Insurance Plan Address for DENTAL claims:
City:	State:	Zip:
Insurance Phone:
Do you have a secondary insurance plan?		Yes	No
Dental History
What prompted you to seek dental care for your child at this time?
Date of child's last cleaning and exam?
Has your child had any difficulty accepting dental treatment previously?		Yes	No
If so, please explain
Medical History
Physician's Name	Last Visit
Phone Number
Is you child being treated by a physician now? If so, for what?		Yes	No
Taking any medication? If so, for what?		Yes	No
Allergic to any medication? If so, for what?		Yes	No
Has your child had any Recent Illness? If so, for what?		Yes	No
Personal History (hold down the ctrl key to select all that apply)

Thank you for your cooperation. If there is any other information which you feel would be a value, please let us know. I understand that the information above is necessary to provide my child with dental care in a safe and efficient manner. To my knowledge answers are correct and complete. Realizing that the use of anesthetic agents embodies certain risks, I will inform this office of any changes in my child’s medical history. I further authorize and consent that Doctor Reynolds and/or his assigned may utilize diagnostic aids deemed appropriate and perform all forms of treatment, medication, and therapy deemed necessary in connection with the dental care of until written notice is given discontinuing this permission.

AIDS
Allergies
Amoxicilin Allergy
Anaprox Allergy
Anemia
Anti-inflammatories
Arthritis
Artificial Joints
Asprin Allergy
Asthma
Bactrim
Blood Disease
Cancer
Codeine Allergy
Demoral Allergy
Dizziness
Epilepsy
Epinephrine
Erythromycin Allergy
Fainting
Growths
Head Injuries
Heart Disease
Hepatitis
Iodine Allergy
Keflex Allergy
Liver Disease
Local Anes. Allergy
Lorocet Allergy
Mental Disorders
Mercury Allergy
Mitral Valve Prolapse
Morphine Allergy
Motrin Allergy
Nervouce Disorders
High Blood Pressure
Pacemaker
Penicilin Allergy
Percodan Allergy
Raditaion Treatment
Respritory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Sulfa Allergy
Tetracycline Allergy
Thyroid Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease