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Happy Kids Pediatric Dentistry
Dr Cruz Maria Ceino
“Where Magical Smiles Beginn”

Patient Information

Mother´s information

Father´s information

Person Financially responsible for account

Insurance information

Has your child ever been hospitalized? If yes, please describe when and why:
Y or N Has your child ever been treated in an emergency room? If yes, explain:
Y or N Has your child ever had surgery? If yes, explain:
Y or N Does your child need premedication with antibiotic before dental treatment? Please list all current medications this patient is taking and include reason for taking:

Has your child ever been diagnosed with or treated for the following?

ADHD/Hyperactivity
Artificial Joints
Birth Defects
Breathing Problems
Developmental Delay
Heart Murmur
Kidney Disease
Liver Disease
Mental/Nervous Disorder
Premature Birth
Seizures/Epilepsy
Sickle Cell Disease
Tuberculosis
Anemia
Asthma
Cancer/Tumor
Delayed Speech
Fainting Spells
Diabetes
Sinus Problems
Low Birth Weight
Autism
Do you have any concerns regarding his/her teeth?
Do you supervise your child in brushing his/her teeth?
Does your child has any jaw/muscle discomfort?
Does your child drink bottled, high filtered or well water?
Does your child has click, pop, or other noise in the jaw joint?
Does your child frequently eat sweets and or drink juices or soda?
Are any teeth uncomfortable when chewing?
Does your child’s gums bleed when brushing?
Does your child has any history of an accident/injury involving teeth?
Does your child have history of snoring or mouth breathing?
Does your child suck their thumb or a pacifier?
Does your child has a history of going to sleep with a bottle?
Does your child use fluoride toothpaste, tablets or rinses?
Does your child clench or grind his/her teeth?
Does your child teeth have sensitivity to cold or hot?
Does your child reacts well to dental procedures?

I, the undersigned parent/legal guardian of this child, certify that the above is accurate and complete to the best of my knowledge. I will notify Dr. Ceino and/or the staff of any changes in the above prior to appointment.

Appointment Policy

¡Gracias por tu mensaje!

Happy Kids Pediatric Dentistry
Dr Cruz Maria Ceino
“Where Magical Smiles Begin”

Información del paciente

Información de la madre

Información del padre

 Persona responsable por la financiación

 información del seguro