PPFDdesk New Patient Form (Child)
Welcome to Paw Paw Family Dentistry! Thank you for completing each question to the best of your ability. 
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Email *
32800 E Red Arrow Highway
Paw Paw, MI 49079
269-657-4001
Today's Date: *
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Child's Last Name *
Child's First Name and Middle Initial *
Nickname/Preferred Name:
Child's Birthdate: *
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Child's Age: *
Gender *
Home Address (Including CITY, STATE, ZIP) *
Home Phone and/or Cell Phone: *
Social Security Number: *
Other family members who have seen us:
Child's grade in school:
Who is accompanying the child on their first visit? *
Do you have legal custody of this child? *
Is this child adopted?
Clear selection
Is the child in a foster home?
Clear selection
Who is responsible for the dental payments? *
Emergency Contact's Name and Phone Number *
I understand that payment is due at time of service: *
We do NOT bill to medical, ortho, workers' comp, auto, or lawsuits (i.e. restaurants, playground, etc.) *
Required
Insurance Company Name:
(Type N/A or "none" if not applicable.)
 *
Insurance Company Phone Number:
Insurance Company Group# (Plan, Local, or Policy#):
Insurance Company Address:
Insured's Name:
(The full name of the person who carries the insurance for the child.)
ID# or SS# of the INSURED:
INSURED's Birthdate:
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INSURED'S relation to the child:
Secondary Insurance Company (if applicable):
Secondary Insurance Phone Number:
Secondary Insurance Group Number:
Secondary Insurance Address:
What brings this child to our practice? *
Required
Check each box that applies to the child: *
Required
Does / did the child have any of the following habits? *
Required
Does the child have a GENERAL DOCTOR / PHYSICIAN? *
Physician's Name:
Date of last visit:
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Physician's Phone Number:
Check YES, if the box applies to the CHILD: *
Required
Check the box if child is allergic to any of the following: *
Required
Please list all drugs and / or other allergies that cause the child allergic reactions:
Please list all drugs that the child is currently taking:
Is the child taking any prescription, over-the-counter drugs, herbal remedies, vitamins or minerals not listed above? If yes, please list each one:
What pharmacy do you use and what is the phone number there?
Please share any serious medical problems the child experiences/experienced:
I affirm that the information I have given to Paw Paw Family Dentistry is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in the child's medical/health status.  *
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