Patient Medical and Dental HistoryChild's Name* Gender* Male Female Child's Nickname Age*Date of Birth* MM slash DD slash YYYY Pediatrician* Pediatrician's Phone Number Who may we thank for referring you?* MEDICAL HISTORY: Has your child experienced any of the following?:Autism* Yes No Anemia* Yes No Asthma, Lung Disease or Breathing Problems* Yes No Bleeding Problems, Hemophilia* Yes No Cerebral Palsy* Yes No Delayed Speech Development* Yes No Developmentally Delayed* Yes No Diabetes* Yes No Thyroid or Glandular / Endocrine Problems* Yes No ADHD / Behavioral or Learning Problems* Yes No Fainting Spells* Yes No AIDS, HIV Positive* Yes No Heart Condition, Murmur* Yes No Jaundice, Liver Disease, Hepatitis* Yes No Kidney Disease* Yes No Ear Infections, Hearing Loss or Impairment* Yes No Special Needs, Mentally Handicapped* Yes No Psychiatric Problems* Yes No Seizures, Epilepsy* Yes No Rheumatic Fever* Yes No Sickle Cell Anemia* Yes No Frequent Headaches* Yes No Congenital Birth Defects* Yes No Arthritis, Auto-Immune or Connective Tissue Diseases* Yes No Cancer, Tumor, Leukemia* Yes No Frequent Infections* Yes No Eye Disease* Yes No Hypertension, High Blood Pressure* Yes No Any Other Medical History of Concern* Yes No DENTAL HISTORY:Do you have a dental related concern? Yes No If Yes, Explain:* Is your child experiencing any of the following?:Cleft Lip / Palate* Yes No TMJ/TMD Problems* Yes No Latex Allergy* Yes No Thumb / Finger / Pacifier* Yes No List Food or Medication Allergy* Problems Sleeping at Night* Yes No Snoring* Yes No Currently Using Bottle or Sippy Cup* Yes No Currently Nursing* Yes No Trouble Breastfeeding at Birth* Yes No Please list any medications, vitamins or health supplements your child is currently taking:Please complete the following questionnaire as thoroughly as possible. The information will be valuable assistance to us in establishing meaningful communication with your child.Will your child be a cooperative patient? Explain:* Favorite hobbies, games* Does your child have any pets?* Names of brothers and sisters* School and grade* Resposible Party InformationName* Address* City State Zip Phone E-mail* Date of Birth* MM slash DD slash YYYY Occupation Employer's Address Spouse InformationSpouse's Name Address(if different) City State Zip Phone E-mail Date of Birth MM slash DD slash YYYY Occupation Employer's Address Consent The signature affixed below authorizes examination and treatment by Drs. Setzer, Cochran, Soares and/or Drs. Setzer, Cochran, Soares and their staff, and further, use of those procedures which in the judgement of the doctor are necessary during the delivery of dental care. I understand that Drs. Setzer, Cochran, Soares PA, may not be a contracted provider for my insurance company, and that our office will be filing to my insurance company as a courtesy and expect their payment in 30 days. I recognize that it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by the insurance company. I hereby assign all dental and/or surgical benefits, to include major benefits to which I am entitled, including private insurance and other health plans to: Drs. Setzer, Cochran, Soares PA. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assigns to release all information necessary to secure the payment. Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in regards to your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)May we request of your child's medical records for our references?* Yes No May we forward information regarding your child's dental records to your primary care physician and/or Dentist?* Yes No NameThis field is for validation purposes and should be left unchanged.