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LOS GATOS        WILLOW GLEN 

CHILD’S FULL NAME NICKNAME
DATE OF BIRTH MALEFEMALE
CHILD’S INTEREST/HOBBIES PETS
OTHER CHILDREN IN FAMILY (NAME AND AGES)  
SCHOOL ATTENDING GRADE
WHO MAY WE THANK FOR REFERRING YOU?  
WHO IS CHILD LIVING WITH?  
PARENT/GUARDIAN 1 NAME  
PARENT/GUARDIAN 1 HOME ADDRESS CITY/ZIP
PARENT/GUARDIAN 1 HOME PHONE

 
PARENT/GUARDIAN 1 BUSINESS ADDRESS

 
PARENT/GUARDIAN 1 BUSINESS PHONE

CELL
PARENT/GUARDIAN 1 OCCUPATION

EMPLOYED BY
PARENT/GUARDIAN 1 SOCIAL SECURITY OR

INSURANCE ID #

PARENT/GUARDIAN 1 BIRTHDATE
PARENT/GUARDIAN 1 EMAIL ADDRESS  
PARENT/GUARDIAN 2 NAME  
PARENT/GUARDIAN 2 HOME ADDRESS CITY/ZIP
PARENT/GUARDIAN 2 HOME PHONE  
PARENT/GUARDIAN 2 BUSINESS ADDRESS  
PARENT/GUARDIAN 2 BUSINESS PHONE CELL
PARENT/GUARDIAN 2 OCCUPATION EMPLOYED BY
PARENT/GUARDIAN 2 SOCIAL SECURITY OR

INSURANCE ID #

PARENT/GUARDIAN 2 BIRTHDATE
PARENT/GUARDIAN 2 EMAIL ADDRESS  
IN CASE OF EMERGENCY, WHO SHOULD BE NOTIFIED PHONE
PERSON RESPONSIBLE FOR THIS ACCOUNT  
DENTAL INSURANCE  
PRIMARY CARRIER EMPLOYEE NAME
GROUP NUMBER
SECONDARY CARRIER EMPLOYEE NAME
GROUP NUMBER
CHILD’S PHYSICIAN
ADDRESS PHONE
APPROXIMATE DATE OF LAST VISIT
REASON FOR VISIT
IS CHILD CURRENTLY RECEIVING ANY MEDICATIONS OR DRUGS? YESNO
NAME REASON
DOES CHILD BLEED EXCESSIVELY WHEN CUT? YESNO
IF YES EXPLAIN
HAS CHILD EVER BEEN HOSPITALIZED? YESNO
Explain
DOES YOUR CHILD HAVE BEHAVIOR OR EMOTIONAL PROBLEMS? YESNO
EXPLAIN
DOES YOUR CHILD HAVE ANY PHYSICAL HANDICAPS OR LEARNING DISABILITIES? YESNO
EXPLAIN
HAS YOUR CHILD EVER HAD ANY BAD DENTAL EXPERIENCES OR UNUSUAL FEARS ABOUT DENTISTRY? YESNO
IS CHILD TAKING ANY FORMS OF FLUORIDE? YESNO WHAT KIND?
Are there any known allergies including medications, nuts, or latex? YESNO
EXPLAIN
HOW OFTEN DOES YOUR CHILD BRUSH AND FLOSS HIS OR HER TEETH?
DOES CHILD RECEIVE HELP BRUSHING AND FLOSSING? YESNO
IS YOUR CHILD USING NURSING BOTTLE? YESNO
DOES YOUR CHILD HAVE ANY HABITS SUCH AS THUMB OR FINGER SUCKING, PACIFIER, ETC.? YESNO
PLEASE DESCRIBE
DOES YOUR CHILD HAVE ANY SPEECH PROBLEMS, NAIL BITING, NOISY EATING, SNORING, TEETH GRINDING, OR DIFFICULTY SWALLOWING? PLEASE NOTE: YESNO
HAVE YOU OR YOUR SPOUSE HAD ANY SERIOUS DENTAL PROBLEMS? YESNO
HAS YOUR CHILD HAD ANY OF THE FOLLOWING?
AIDS CEREBRAL PALSY HEART DISEASE
MONONUCLEOSIS ANEMIA CHICKEN POX
HEMOPHILIA MUMPS ASTHMA
CONVULSIONS HEPATITIS IN FAMILY PSYCHIATRIC TREATMENT
BIRTH DISEASE DIABETES HIV-POSITIVE
RHEUMATIC FEVER BLADDER DISEASE DRUG PROBLEMS
KIDNEY DISEASE SCARLET FEVER BLOOD DISEASE
EPILEPSY LIVER DISEASE SINUS INFECTION
BLOOD TRANSFUSION FAINTING MALIGNANCIES
THYROID BRONCHITIS HEARING PROBLEMS
MEASLES TUBERCULOSIS  
ARE THERE ANY OTHERS FACTS ABOUT YOUR CHILD YOU FEEL WE SHOULD KNOW OR YOU WOULD LIKE US TO CONSIDER?