Welcome to Sunrise Pediatric Dentistry.

Please note: If you plan on using dental insurance for your child's visit, you must include that information below. If we do not have that information 24 hours prior to your appointment, please plan to our office arrive 30 minutes early with your insurance card. This will ensure that we have ample time to review your benefits at the time of your child's visit and answer any questions you may have. We appreciate your help!

Please complete this form for new patients ages 18 plus.

Today's Date *
Today's Date
Patient's Name *
Patient's Name
Birthday *
Birthday
Gender *
Address *
Address
Phone Number *
Phone Number
Parent or other Emergency Contact *
Parent or other Emergency Contact
This may be a different company than your medical insurance.
Subscriber's Name
Subscriber's Name
Subscriber's Birthday
Subscriber's Birthday
This may be the subscriber's social security number if you did not receive an insurance card.
If online please let us know which site (Google, Facebook etc.)
We would like to have it playing for you!
If you see one
If yes, how often
Medical History
For the following questions you only need to click if the answer is yes. Please provide details at the end of the section for any positive responses.
Any problems with growth & development, birth defects, syndromes or inherited conditions?
Any problems with growth & development, birth defects, syndromes or inherited conditions?
Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat, or high blood pressure)
Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat or high blood pressure
Asthma or breathing problems
Bladder or kidney problems
Jaundice, hepatitis or liver problems
Gastroesophageal/acid reflux or stomach problems
Developmental disorder, learning problems/delays, autism, cerebral palsy, ADD/ADHD
Epilepsy, convulsions/seizures
Diabetes, thyroid or other endocrine problems
Hemophilia, bleeding disorders or taking anticoagulation medications
Cancer or other malignancies
History of problems with sedation and/or anesthesia
Infectious diseases (hepatitis, HIV/AIDS, MRSA, Tuberculosis, endocarditis, recurrent/frequent infections, infections requiring hospitalization or IV antibiotics)
Females only
If yes, how many weeks
Dental History
Do you have any habits?
Any jaw joint problems (clicking, popping, pain)?
What kind of toothpaste do you use? *
If yes, please describe and list name of treating orthodontist
Have you ever had a difficult dental appointment? *