David M. Kang DDS, Carol K. Yeung DDS

1770 East Lambert Road Suite 210, Brea, California, 92821

714-255-8338, 714-255-1326

Patient Information

Patient Name:
Date of Birth:
Phone:
Email:
PATIENT’S PEDIATRICAN:
PATIENT’S SCHOOL:
PEDIATRICAN ADDRESS:
City:
Zip Code:
PEDIATRICAN PHONE #:
LAST MEDICAL EXAM:
PREVIOUS DENTIST:
LAST DENTAL EXAM:
PATIENT’S ORTHODONTIST:
LAST ORTHODONTIC EXAM:
List any medication(s) and dosage your child is taking:

FAMILY RECORD AND FINANCIAL RESPONSIBILITY

WELCOME! How did you choose our office?
Reason for this appointment

FAMILY RECORD

Name(s) and age(s) of children to be seen on your initial visit:
Have any family members been patients in our office in the past?
If so, please list:
Patient(s) main residences address:
City:
State:
Zip Code:
Father’s full name:
Marital Status:
Address (if different):
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone:
Work address:
Driver’s License #:
Mother’s full name:
Marital Status:
Address (if different):
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone:
Work address:
Driver’s License #:
Emergency Contact Name:
Relationship:
Phone:
If family is NOT living together, person(s) financially responsible for account:

DENTAL INSURANCE INFORMATION

First Policy

Name of insured:
Relation to child:
Social Security #:
Birth Date:
Group / Policy#:
Ins. Co.:
Employer:
Employee ID#:

Second Policy

Name of insured:
Relation to child:
Social Security #:
Birth Date:
Group / Policy#:
Ins. Co.:
Employer:
Employee ID#:

INFORMED CONSENT

I authorize my insurance company to pay Brea Pediatric Dental Practice all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance and that all payments are due when services are rendered. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Brea Pediatric Dental Practice. This consent is to remain in effect until canceled in writing.

Brea Pediatric Dental Practice

Patient Name:
Birth Date:
Pediatrician:
Does your child have a current Pediatrician or Primary Doctor?
If so, please provide Name, Address, Phone number below:
Does your child have any physical or learning disabilities or attending any theraphy? If so, please list
Was your child born premature?
If yes
Is your child currently being seen by a physician on a regular basis? (Ex: monthly, weekly, etc)
If Yes
Has your child ever had a head or neck injury? (Ex: Hit to the face, head, or teeth)
If Yes
Does your child snore or have obstructive sleep apnea?
If Yes
Has your child ever been hospitalized or had any operations?
If Yes
Has your child ever been diagnosed with an Innocent Heart Murmur, or any other cardiac conditions?
If Yes, did the cardiac condition require surgery?
If Yes, do you know if your child requires an antibiotic prior to dental cleanings / restorations?
Does your child take any medication(s) regularly?
If so, please list all medication(s) and dosage your child is taking below.
Is your child allergic to any of the following? List any others that are not listed below (especially fruits and foods)
Latex
Codeine
Eggs
Local Anestetics
Metal
Soy
Sulfa Drugs
Dairy
Milk Protein
Penicillin / Amoxicillin / Augmentin
Nuts
Lactose Intolerant
Does your child take any oral contraceptives?
If Yes
Has or is your child pregnant?
Does or has your child taken any recreational drugs?
Does your child have any oral jewelry, such as tongue or lip piercings?
Does your child have, or had, any of the following?
ADHD
AIDS/ HIV Positive
Anaphylaxis
Anemia
Angina
Artificial Heart Valve
Artificial Joint
Asperger’s Syndrome
Asthma
Autism
Blood Disease
Bruise Easily
Cancer
Cerebral Palsy
Chemotherapy
Chicken Pox
Cold Sores / Fever Blisters
Convulsions
Croup
Depression
Diabetes
Down Syndrome
Emphysema
Epilepsy or Seizures
Frequent Headaches
Hand, Food, Mouth Disease
Hay Fever
Heart Murmur
Heart Pacemaker
Hives or Rash
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
Hypoglycemia
Irregular Hearbeat
Kawasaki Disease
Kidney Problems
Leukemia
Liver Disease
Lung Disease
Mitral Valve Prolapse
MRSA
Osteoporosis
Psychiatric Care
Parathyroid Disease
Radiation Treatments
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Splenectomy
Stomach / Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Whooping Cough
Yellow Jaundice

Habits

Does your child have any of the following habits?
Thumb sucking
Finger / Blanket sucking
Pacifier
Grinding
Nail Biting

I have read all the questions and answered them to my knowledge that everything is correct.

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Guardian's Signature:

Use your mouse cursor or the tip of your finger to sign below

Name:
Date:

Doctor's Signature:

Use your mouse cursor or the tip of your finger to sign below

Name:
Date: