Child Patient Form

Child Registration Form - Dental

Patient Information


Parent / Guardian Information

Parents' Marital Status

Emergency Contact Information

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information

Dental History

How did you hear about our Practice?
Have we treated any other family members?
Have your child's tonsils or adenoids been removed?
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Does your child have any missing or extra permanent teeth?
Has your child ever had an injury to (select all that apply):
Does your child have speech problems?
Does your child currently or has your child ever had any of the following habits (check all that apply)?

Radiograph / X-Ray Information

If you answered YES to any of the questions you will need to retrieve these radiographs prior to any treatment to prevent over exposure to radiation and to decrease the chance of incurring an additional charge for a non‐covered service. You should request these items and bring them with you to your next appointment, (having them in hand prevents the lost in mail syndrome). These questions were included in your new patient packet that was sent to you when you set up your first exam visit.

Medical History

Is your child currently being treated by a physician?
Has your child ever been hospitalized or had a major operation? If yes, describe:
Has your child ever had a serious head or neck injury? If yes, describe:
Is your child currently taking any prescription or over-the-counter medications?
Does your child take, or has your child taken. Phen-Fen or Redux?
Has your child ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Is your child on a special diet?
Does your child use tobacco?
Does your child use controlled substances?
Is your child

Is your child allergic to any of the following?

Check if your child has or has ever had any of the following:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Security Measure

J. A. Lewandowski, D.D.S.

  • J. A. Lewandowski, D.D.S. - 13401 Mission Rd., Suite 212, Leawood, KS 66209 Phone: 913-851-8000

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