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  • MeckDental Patient Information Form

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birth Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Race/Ethnicity:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Referral Information

  • Whom may we thank for referring you to our practice?
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  • Parent or Responsible Party Information

  • The following is for:
  • Birth Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender/Marital Status/Other:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • If you don't have insurance, are you self-pay?
  • Patient's relationship to insured:
  • Is insured a patient?
  • Insured's Birth Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Page 2 of 4

  • Health Information

  • Date of Last Dental Visit:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had any of the following? Please check all that apply:
  • Pregnancy Due Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had any complications following dental treatment?
  • Have you been admitted to a hospital or needed emergency care during the past two years?
  • Are you now under the care of a physician?
  • Format: (000) 000-0000.
  • Do you have any health problems that need further clarification?

  • Emergency Contact

  • Format: (000) 000-0000.

  • Consent for Services

  • To the best of my knowledge, the medical and dental information as answered on this form ins correct. I will inform this office of any changes in health status and/or use of medications.
  • When used for educational purposes, I consent to the use of radiographs, photographs, study models, etc.
  • The signature of a parent or guardian affixed bellow authorize the completion of all agreed upon dental treatment and the use of proper and acceptable methods to perform the same. Alternative methods of treatment, if any, have been explained to me. I am advised that through good results are expected, the possibility of and nature of complications cannot be completely anticipated. Therefore, there can be no guarantee as expressed or implied to the outcome of the treatment provided.
  • I fully understand this content and have no further questions.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Page 3 of 4
  • English

  • Parent / Legal Guardian Responsibilities

  • To ensure the most pleasant and productive dental experience for your child, we request that all Parents/Legal Guardians follow the guidelines listed below:
  • 2. Be prepared to show picture ID and insurance information at each visit.

  • 3. A parent or Legal guardian (court appointed) has to be present for the following types of appointments:

    • New patient exams
    • Emergency (swelling of face or trauma)
    • Recall cleaning
  • 4. Always be available by phone if your child comes for a treatment appointment. If treatment changes from previous plan or behavior management issues rise, we will need to speak with the parent or Legal guardian before proceeding.
  • 5. During your child's visit to our office, a parent, legal guardian or adult representative must be present at all times. (No exceptions will be allowed).
  • 6. Make follow-up appointments as directed for your child's treatment needs. Failure to comply could result in dismissal.
  • 7. At all times, be polite to all staff and other parents/children during your visit.
  • If any of the responsibilities of the parent or legal guardian are not met, the child's appointment may have to be postponed.
  • The following will be cause for immediate dismissal from our dental practice:
  • 1. Breaking 2 appointments within a 12-month period. Broken appointments are defined as: arriving late for appointments, not showing for an appointment or not giving a 24-hour notice of cancellation.
  • 2. Use of profanity and/or creating a hostile environment.
  • We appreciate your confidence in our office and look forward to treating your child's dental needs. If you have any questions, concerns, or complaints, please speak to the Dental Practice Manager.
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