DR. NOREEN B. DOHERTY DR. DAREN A. KING CHILDREN’S DENTIST ORTHODONTIST

1302 CARROLL STREET BROOKLYN, NEW YORK 11213

(917) 740-9340 AND (718) 230-5050

PATIENT INFORMATION PLEASE COMPLETE THE FOLLOWING INFORMATION FOR MINORS AGE 17 & UNDER OR DEPENDENTS DOB:

First MI Last (Preferred Name)

Work #: ______________ Cell #:____________ Best time to call:

Patient Name:

Email:

Home #:

Address: Street Apartment #

City State Zip Code Occupation: _______________________ Place of Business/School: _________________ Bus. Phone:_______________ Gender: Male Female Hobbies: ____________________________________________________ PATIENT HEALTH INFORMATION

Anemia Arthritis Asthma Blood Disease Cancer Chronic Pain Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hemophilia Hepatitis

Does the patient have or ever had any of the following: Y N Y N

High Blood Pressure Jaundice Kidney Disease Liver Disease Low Blood Pressure Mental Disorders Mouth Breather Neurological Disorders Pacemaker Pregnant Due Date:________ Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems

Y N Sore or Ulcers in the Mouth Speech Problems Stomach Problems Stroke Systemic Lupus Erythematosus Tonsils Removed Tuberculosis Tumors Thyroid Problems Ulcers Venereal Disease Emotional Problems Hearing Problems Other: ________________ ________________

Y N Allergies: Local Anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa Drugs Codeine or other narcotics Latex Seasonal Animals Food (specify):_______________

• Is the patient under any medical treatment? Yes No. Explain: _____________________________

• Is the patient currently taking medication? Yes No. Explain: ______________________________

• Has the patient had any recent weight loss or persistent cough? Yes No. Explain: ______________

• Has the patient had any wounds that healed slowly or presented other complications? Yes No.

Explain: __________________________________________________________________________

• Has the patient ever had a habit of sucking a finger, thumb, tongue or other? Yes No.

If yes, which? ____________. What age was this? ______. Has the habit stopped? Yes No

For how long has, or had, the patient had this habit? ___________________.

• Does the patient have any of the following: If yes, please check the following that applies:

Popping/ clicking when opening and closing the mouth? Facial pain

Habitually grinds or clenches teeth during the day or night? Muscle soreness

DR. NOREEN B. DOHERTY DR. DAREN A. KING CHILDREN’S DENTIST ORTHODONTIST

1302 CARROLL STREET BROOKLYN, NEW YORK 11213

(917) 740-9340 AND (718) 230-5050

PATIENT’S DENTAL INFORMATION: Name of Patient’s General Dentist: ______________________________ Phone # ____________________ Dentist’s Address _______________________________________________________________________ Date of Last Dental Visit: _____ How long has it been since patient’s last cleaning? _________________ Reason for this visit: _____________________________________________________________________ PARENT OR GUARDIAN INFORMATION Are parents married, separated or divorced? If separated or divorced, who has custody of patient? Mother Father Other ___________

REFERRAL INFORMATION Whom may we thank for referring you to our practice? Name of person or office referring you to our practice: _________________________ CONSENT FOR SERVICES Under HIPPA, patients will have an increased awareness of their health information privacy rights, including the following:

The right to access, copy, any inspect their health information; The right to request an amendment to their healthcare information; The right to obtain an accounting of certain disclosure of their health information; The right to request restrictions on disclosures for treatment, payment and health care operations; The right to alternative means of receiving communications from dentists; and The right to complain about alleged violations of the regulations and the dentist’s own information policies.

• To the best of my knowledge, all of the preceding answers and information provided are true and correct. If there areany medical changes in my child’s health, I will inform the doctors at the next appointment.

• I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related tothis form and to discuss treatment information to other health professionals and my insurance company as necessary.

• Please note that X-rays, pictures and records maybe used for scientific purposes, research and lectures withoutdisclosure of the patient’s identity.

• I certify that the information supplied is accurate and true to the best of my knowledge. I consent to treatment.X-RAYS: Yes No Only if necessary Please call before — Permission is granted.

I have read the above conditions of treatment and HIPPA Privacy Policy and agree to their content.

____________________________________________ Date: _______________ Relationship to Patient: Signature of parent or guardian

____________________________________________ Print name of parent or guardian

(In separation/divorce situations, the individual initiating service with this office will be held financially responsible for complete payment of services.) Who is the person responsible for the treatment? _____________________________________________________

Guardian’s Name: Occupation:_________________________________

Social Security Number: ____________________________Birth Date: ______________________________________ Place of Business/ Address: ________________________________________________________________________ How many years employment:: ____________ Email Address: ______________________________________ Phone (Work): _____________ Ext: ____ Cell # ______________ Best time to call: A. M.

Name of Dental Insurance: ___________________________ Plan/Group # ___________________________ P. M.

Guardian’s Name: _____________________________________Occupation :__________________________________ Birth Date: __________________________________

Place of Business/ Address _________________________________________________________________________ How many years employment:_______________________ Email Address: ____________________________ Phone (Work): _____________ Ext: ____ Cell # ______________ Best time to call: A. M.

Name of Dental Insurance: ___________________________ Plan/Group # ____________________________ P. M.