Patient Information and Health History Form

Patient Information and Health History Form

Child's Name:
Nickname:
Date of Birth:
Street Address:
City:
State:
Zip:
Home Phone:
SSN:
Age:
Gender:	Male Female

Parent Information

Parent/Legal Guardian 1
Name:
Relationship to patient:
Street Address:
City:
State:
Zip:
Home Phone:
SSN:
Date of Birth:
Cell Phone:
Business Phone:
Email Address:
Dental Insurance:
Employer:
Group #:

Parent/Legal Guardian 2
Name:
Relationship to patient:
Street Address:
City:
State:
Zip:
Home Phone:
SSN:
Date of Birth:
Cell Phone:
Business Phone:
Email Address:
Dental Insurance:
Employer:
Group #:

Whom may we thank for referring you?
Name:
	portpediatric.com Phonebook Dental Office Pediatrician Other

Emergency Contact
Name:
Relationship:
Home Phone:
Business phone:
Cell phone:

Health Care Provider
Child's Physician/Pediatrician:
Office phone:
Mailing Address:
City:
State:
Zip: