Welcome, and thank you for choosing Sunrise Pediatric Dentistry.  The information provided on this form is important to your child's dental health and should be completed by a parent or legal guardian.  Please submit a separate form for each of your children.  We look forward to caring for your family.

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 arrive 30 minutes prior to your appointment time 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 0-17.

Today's Date *
Today's Date
Child's Name *
Child's Name
Birthday *
Gender *
If online please let us know which site (Google, Facebook etc.)
Parent's Name *
Parent's Name
Parent's Birthday *
Parent's Birthday
Phone Number *
Phone Number
Address *
Any other person that may accompany your child to their visit
(This may be a different company than your child's medical insurance)
Name of Subscriber
Name of Subscriber
Subscriber's Birthday
Subscriber's Birthday
This could be the subscriber's social security number if you didn't receive a dental insurance card.
If your child sees one
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.
Was your child born prematurely (before 36 weeks gestation)?
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
Asthma or breathing problems
Bladder and/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 disorder or taking anticoagulation medications
Cancer or other malignancies
History of problems with sedation and/or anesthesia
Infectious diseases (hepatitis, HIV/AIDS, MRSA, Tuberculosis, endocarditis, frequent/recurrent infections, or infections requiring hospitalization/IV antibiotics
Dental History
Any jaw joint problems (pain, clicking or popping)?
Does your child have any habits?
Does your child sleep with a bottle or sippy cup?
Ages 5 and under only
What kind of toothpaste do you use? *
If yes, please describe and list name of treating orthodontist
Has your child ever had a difficult dental appointment? *