Online Application

Fields marked with (*) are mandatory

PATIENT INFORMATION AND MEDICAL HISTORY

Randy Hamilton III DMD Responsible Party (Parent / Guardian) Information Name * Relationship * Social Security # * Date of Birth * Sex * Select Male Female Home Address * Child Information City / State / Zip * Last Name * Home Phone First Name * Cell phone Social Security # * Work Phone Date of Birth * Other Phone Sex * Select Male Female Employer * Insurance Email Address * Medicaid ID # How Did You Hear About Us? Online Newspaper TV Blog Others

HAS YOUR CHILD EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING CONDITIONS? PLEASE CHECK YES OR NO.   Y N   Y N   Anemia Congenital Heart Disease Asthma Kidney Disease Autism Convulsions / Seizures Bladder Conditions Diabetes Birth Defects Emotional Disturbances Blindness Epilepsy Cancer or Malignancies Excessive Bleeding Problems Cerebral Palsy Excessive Gagging Child Abuse Fainting or Dizziness Chronic Adenoid / Tonsil Growth and Dev. Problems Chronic Headaches Handicap / Impairments Chronic Ear Infections Hearing / Speech Problems Cleft Lip / Palate HIV / AIDS Heart Murmur Rheumatic Fever Hepatitis or Liver Disease Sickle Cell Anemia Hospital Admission Snores when Asleep Hyperactivity Tuberculosis Premature Birth Mental Retardation Oral Ulcers             Other

Describe Your Child's Previous Dental Experience

Any Unfavorable Reactions to Dental Treatment?

How Long Has it Been Since Your Child's Last Dental Visit?

PATIENT INFORMATION AND MEDICAL HISTORY   List Your Reasons for Today's Visit * Is Your Child Receiving Medication or Care from Any Other Healthcare Provider? Y / N * Select Yes No Name of Provider * Phone Number * Reason for Care or Treatment * Has Your Child Been Hospitalized? Y / N * Select Yes No If Yes, Explain * List All Medication or Drugs Your Child is Presently Taking * List Any Drug, Food, Latex, etc. ALLERGIES *   Patient / Responsible Party Signature * Date *