New Patient Dental Online Forms

Welcome to Brush n Brace! In order to make it easy for your first visit with us, you can fill out our new patient dental form electronically.
If you have any questions you can always call our office at: (858) 800-2000 and we’ll be more than happy to help you out. If you’re not able to fill it out before the appointment, then please arrive 10-15 minutes before your child’s appointment. Thank you!

NEW PATIENT DENTAL FORMS – NEEDED FOR YOUR FIRST VISIT

First, let’s get the boring stuff out of the way. For your first visit, we will need information about you.

We have 2 forms, one to be filled out by one of your parent’s/guardian and one to be filled out by you! It’s not too complicated, you can either fill it out on our secure server or download the form and email it back to us! We’ve tried to make it as easy, breezy for you! If you need any help, just give us a ring, we’re here for you!

All information is transmitted over a secure connection and will never be distributed or sold to any third parties. We are compliant and observe all HIPAA Regulations.

Form to be filled out by Parent/Guardian

Form Submission is restricted

Form is successfully submitted. Thank you!

New Patient Dental Form

PATIENT INFORMATION

MEDICAL & DENTAL INFORMATION

Responsible Party & Insurance Information

Child's first & last name*

Preferred name

Sex*

Male

Female

Birth date*

Age

Previous dentist

Date of last visit

Who has legal guardianship of your child?*

Your child's attitude towards previous dental care?

Reason for this visit?

How did your hear about our office?*

Names & ages of sibling(s)

Is your child engaged in social media?

Yes

No

I don't know

Child's cell

Child's email

 

MEDICAL INFORMATION

Doctor's name, address & phone

Is your child taking any kind of medication?*

Yes

No

If so, what kind & what for?

Has your child every been hospitalized?*

Yes

No

If so, when & for what reason?

Has your child had a history with any of the following:*

No to all

Seasonal allergies

Autism

Cancer/Tumors

Developmental

Hearing

Hepatitus

General Anesthesia/Surgery

Syndromes

Asthma/Breathing problems

Anemia/Bleeding

Cerebral Palsy

Diabetes

Heart

Immune deficiency

Seizures/Epilepsy/Convulsions

Arthritus

Bones

Cleft lip/Palate

Eyes, ears, nose, throat

Kidney

Liver

Stomach/Intestinal

Other

Comments/Details?

Does your child have any emotional or school problems?

Allergies to Food or Medications?*

DENTAL INFORMATION

Has your child ever had any injuries to his teeth, mouth or head?*

Yes

No

If so, when? Please provide details

Does your child brush regularly?

Yes

No

How often?

Does your child floss?

Yes

No

How often?

Has either parent or child been treated orthodontically?

Yes

No

Name of Orthodontist

How do you expect your child’s reaction will be towards receiving dental care in our office?

Describe your child:

Outgoing

Shy

Rebellious

Anxious

Other

How may we help to make dental visits a positive experience for your child?

 

RESPONSIBLE PARTY INFORMATION

(holder of insurance)

First name*

Last name*

Relationship to patient

Mother

Father

Legal Guardian

Other

Address*

City, State, Zip*

Cell Phone*

Other Phone

Date of birth*

Social Security Number

Employer

Email Address

We do all our communications/confirmations via email and we NEVER spam.

Who can we thank for referring you to our practice?*

Parent's Information (Mom or Dad)

(If different from responsible party)

Name

Employer

Occupation

Address

Cell Phone

Date of Birth

PRIMARY DENTAL INSURANCE

Policy Holder's Name

Social Security Number

Policy Number

Insurance Company

Insurance Address

Insurance Phone

Does your child have secondary dental insurance?

Yes

No

FINANCIAL POLICY
Your child’s estimated share of cost is due and payable on the day the treatment is performed. Understand that dental insurance usually covers only part of the fees for services based on your specific dental benefit underwriting. We do our best to provide you with an estimate accordingly. Please understand that the contract for dental insurance is between you and your insurance company and not our practice. Any disputes of coverage need to be handled through the insurance company directly by you and you accept personal financial responsibility for services provided. Your signature here authorizes assignment of benefits to us so we can submit claims. To avoid missed appointment charges we request that you inform us of cancelation notice 48 hours prior to the appointment, so that we can offer the appointment to another child. If you have 2 broken appointments, you will be automatically charged $50.00 for your missed appointments. A broken appointment is considered a “no show” or cancelling an appointment the same day. The signature of the responsible party / Legal Guardian below authorizes Dr. J Shahangian or qualified assignee to complete an oral evaluation including but not limited to examination, cleaning, fluoride and/or diagnostic X-rays as indicated to evaluate oral health.

Signature*

The signature of the responsible party / Legal Guardian below authorizes Dr. J Shahangian or qualified assignee to complete an oral evaluation including but not limited to examination, cleaning, fluoride and/or diagnostic X-rays as indicated to evaluate oral health.

Date*

 

Submit

Fill out our new patient dental forms online, before your appointment at Brush n Brace in San Diego CA. A specialty office for teens.

Do you have some pictures or x-rays you would like to send us before your visit? Click here to upload them to our secure server.

Alternate way to fill out new patient paperwork (you do not need to do both)

You can download form to your computer and email it to us at: staff@scrippspediatricdentistry.com

We do ask that you fill it out and email the form to us as soon as possible so that we can have everything ready for your appointment.

Please save the file to your computer and open the file with Adobe Reader. If you do not have Adobe reader installed on your computer, you can download it for free at: https://get.adobe.com/reader/

Once the file is open in Adobe Reader, please type in your answers and save file. You don’ need to worry about signing the form, we can do that here at the office.

Download new patient dental form