Porter Ranch Patient Forms


Patient Personal Information


Emergency Contact

Health History

Is your child in good health?

Has your child ever had a health problem?

Has your child ever been hospitalized or had surgery?

Was there excessive bleeding when cut?

Is your child allergic to anything?

Is your child currently taking any medications?

Were there any problems at birth?

Please check if your child has been treated for any of the following:

Dental History

Has your child ever had a dental visit?

Has your child experienced any unfavorable reaction from previous dental care?

Does your child suck a finger, thumb, or pacifier?

Does your child have pain with chewing, yawning, or wide opening?

Does your child breathe mainly through the mouth?

Does your child grind his/her teeth?

Does your child snore?

Please check if your child is having problems with any of the following:

Insurance Company

Is patient covered by additional insurance?


I, the undersigned certify that I (or my dependent) have insurance cover with the insurance company(ies) above and assign payment directly to doctor. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Consent for Dental Treatment

I request and authorize any doctor at Kidz Dental Care to examine, clean, and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by any doctor at Kidz Dental Care to diagnose and/or treat my child’s dental problem. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Any doctor at Kidz Dental Care will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation, and demonstration of procedures and instruments, using variable voice tone and stabilization with a pedowrap. I will be responsible for any charges incurred on this child for dental treatment.

I understand that collection actions may taken if my balance goes beyond 90 days.

I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.

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  • Monday - Friday
  • Saturday - Sunday
  • 9:00 am - 5:00 pm
  • Closed
  • Monday - Friday
  • Saturday - Sunday
  • 8:00 am - 5:00 pm
  • Closed
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