Utah Kids Dentists

Meet Our Specialized Pediatric Dentists

CHILD’S NAME: First Name* Last Name* Birthdate * Age* School* Home Address* City* State* Zip Code* Gender MaleFemale Child lives with: (select one)* FatherMotherBothOther Marital status of parents: (select one)* MarriedSingleDivorcedSeparatedWidowed FATHER: First Name* Last Name* Social Security Number* Cell Phone* Home Phone Birthdate* Employer* Work Phone* E-mail Address* Home Address (if different than child’s) MOTHER: First Name* Last Name* Social Security Number* Cell Phone* Home Phone Birthdate* Employer Work Phone E-mail Address* Home Address (if different than child’s) Please choose preffered location: South DavisRedwoodStansbury ParkHerriman PAYMENT OPTIONS: Method of payment (please select one)* PRIMARY DENTAL INSURANCE: Subscriber Name Phone Subscriber ID/SSN Address Insured Person's Name SECONDARY DENTAL INSURANCE: Name Phone Policy Address Insured Person's Name HEALTH (medical) INSURANCE INFO: Name Address Phone Insured Persons Name REFERRAL INFORMATION: Which dentist recommended you to us? DENTAL HISTORY Reason for your child's visit? Is there a specific problem? Has your child been to the dentist before? Date? How was your child's experience?

Is your child's currently taking floride? How often? Has your child had X-Rays before? When? Is your child currently on the bottle? Pacifier Sippy cup? Nursing Thumb sucking? Grinding? Do you currently help your child brush and floss? How ofted does He or She brush? Does your child have TMJ/TMD? MEDICAL HISTORY Name of Physician Is your child's currently taking medication? If yes, what? Has your child ever had a traumatic medical/dental injury? If yes, for what? Date? Has your child ever been hospitalized? If yes, for what? Date? DOES YOUR CHILD HAVE, OR PREVIOUSLY HAD, ANY OF THE FOLLOWING Please check all that apply

Autistm ADHD Aids Allergies Anemia Artificial Joints Athsma Blood Disease/Disorder

Blood Transfusion if yes, date:

Behavioral/Learning Disorder

Breathing/Lung Problems if yes, explain:

Cancer/Tumor Congenital Birth Defects Multiple Ear Infections

Tubes In Ears Endocrine System Fainting Hearing/Vision Heart Murmur Heart Condition Head Injury Frequent/Recurrent Headaches Kidney Disease Liver Disease Mental Disorder Mental/Physical Developmental Delay

Pregnancy if yes, due date:

Gi System

Radiation Treatement Respitory Treatement Respitory Problem Rheumatic Fever Seizures Tuberculosis Down Syndrome Vomiting/Diarrhea

Allergies/Adverse Reaction to Medication if yes, what type:

Frequent Infections if yes, what type:

Any other medical conditions not listed:

If you’ve checked any box above, please describe your situation in detail. I have completed this form with the most accurate information I have, and understand that I am responsible for what I have submitted

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Dentists on Our Team

Years Combined Experience

In-house Sedations

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